hospital_name,last_updated_on,version,hospital_location,hospital_address,license_number|KS,"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.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Kearny County Hospital,1/1/2025,2.0.0,Kearny County Hospital,"500 E Thorpe St, Lakin, KS 67860",H-047-001,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,modifiers,standard_charge | AETNA | negotiated_dollar,standard_charge | AETNA| negotiated_percentage,standard_charge | AETNA| negotiated_algorithm,estimated_amount | AETNA,standard_charge | AETNA | methodology,additional_payer_notes | AETNA,standard_charge | BCBS | BCBS PPO | negotiated_dollar,standard_charge | BCBS | BCBS PPO | negotiated_percentage,standard_charge | BCBS | BCBS PPO | negotiated_algorithm,estimated_amount | BCBS | BCBS PPO,standard_charge | BCBS | BCBS PPO | methodology,additional_payer_notes | BCBS | BCBS PPO,standard_charge | UNITED HEALTHCARE | negotiated_dollar,standard_charge | UNITED HEALTHCARE | negotiated_percentage,standard_charge | UNITED HEALTHCARE | negotiated_algorithm,estimated_amount | UNITED HEALTHCARE,standard_charge | UNITED HEALTHCARE | methodology,additional_payer_notes |UNITED HEALTHCARE,standard_charge | CIGNA | negotiated_dollar,standard_charge | CIGNA | negotiated_percentage,standard_charge | CIGNA | negotiated_algorithm,estimated_amount | CIGNA,standard_charge | CIGNA | methodology,additional_payer_notes |CIGNA,standard_charge | WPPA | negotiated_dollar,standard_charge | WPPA | negotiated_percentage,standard_charge | WPPA | negotiated_algorithm,estimated_amount | WPPA,standard_charge | WPPA | methodology,additional_payer_notes | WPPA,standard_charge | Min,standard_charge|Max,additional_generic_notes
ROOM/BED: Bariatric Room,1000,CDM,120,RC,,,,,Outpatient,,,1482,,,,80,,1185.6,percent of total billed charges,,,,85,1259.7,percent of total billed charges,,,77.7,,1151.51,percent of total billed charges,,,95,,1407.9,percent of total billed charges,,,60,,889.2,percent of total billed charges,,889.2,1407.9,
ROOM/BED: Bariatric Room,1000,CDM,120,RC,,,,,Inpatient,,,1482,,,,80,,1185.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1151.51,percent of total billed charges,,,95,,1407.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1407.9,
ROOM/BED: SB Skilled - Bariatric,1002,CDM,120,RC,,,,,Outpatient,,,1309,,,,80,,1047.2,percent of total billed charges,,,,85,1112.65,percent of total billed charges,,,77.7,,1017.09,percent of total billed charges,,,95,,1243.55,percent of total billed charges,,,60,,785.4,percent of total billed charges,,785.4,1243.55,
ROOM/BED: SB Skilled - Bariatric,1002,CDM,120,RC,,,,,Inpatient,,,1309,,,,80,,1047.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1017.09,percent of total billed charges,,,95,,1243.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1243.55,
ROOM/BED: LDRP Room,12005,CDM,110,RC,,,,,Outpatient,,,1248,,,,80,,998.4,percent of total billed charges,,,,85,1060.8,percent of total billed charges,,,77.7,,969.7,percent of total billed charges,,,95,,1185.6,percent of total billed charges,,,60,,748.8,percent of total billed charges,,748.8,1185.6,
ROOM/BED: Private,12005,CDM,110,RC,,,,,Outpatient,,,1248,,,,80,,998.4,percent of total billed charges,,,,85,1060.8,percent of total billed charges,,,77.7,,969.7,percent of total billed charges,,,95,,1185.6,percent of total billed charges,,,60,,748.8,percent of total billed charges,,748.8,1185.6,
ROOM/BED: LDRP Room,12005,CDM,110,RC,,,,,Inpatient,,,1248,,,,80,,998.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,969.7,percent of total billed charges,,,95,,1185.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1185.6,
ROOM/BED: Private,12005,CDM,110,RC,,,,,Inpatient,,,1248,,,,80,,998.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,969.7,percent of total billed charges,,,95,,1185.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1185.6,
ROOM/BED: Nursery,13003,CDM,170,RC,,,,,Outpatient,,,1142,,,,80,,913.6,percent of total billed charges,,,,85,970.7,percent of total billed charges,,,77.7,,887.33,percent of total billed charges,,,95,,1084.9,percent of total billed charges,,,60,,685.2,percent of total billed charges,,685.2,1084.9,
ROOM/BED: Nursery,13003,CDM,170,RC,,,,,Inpatient,,,1142,,,,80,,913.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,887.33,percent of total billed charges,,,95,,1084.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1084.9,
ROOM/BED: Nursery Level I,13004,CDM,171,RC,,,,,Outpatient,,,1344,,,,80,,1075.2,percent of total billed charges,,,,85,1142.4,percent of total billed charges,,,77.7,,1044.29,percent of total billed charges,,,95,,1276.8,percent of total billed charges,,,60,,806.4,percent of total billed charges,,806.4,1276.8,
ROOM/BED: Nursery Level I,13004,CDM,171,RC,,,,,Inpatient,,,1344,,,,80,,1075.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1044.29,percent of total billed charges,,,95,,1276.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1276.8,
ROOM/BED: Semi Private,22004,CDM,120,RC,,,,,Outpatient,,,1248,,,,80,,998.4,percent of total billed charges,,,,85,1060.8,percent of total billed charges,,,77.7,,969.7,percent of total billed charges,,,95,,1185.6,percent of total billed charges,,,60,,748.8,percent of total billed charges,,748.8,1185.6,
ROOM/BED: Semi Private,22004,CDM,120,RC,,,,,Inpatient,,,1248,,,,80,,998.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,969.7,percent of total billed charges,,,95,,1185.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1185.6,
ROOM/BED: Nursery Level II,23002,CDM,172,RC,,,,,Outpatient,,,1522,,,,80,,1217.6,percent of total billed charges,,,,85,1293.7,percent of total billed charges,,,77.7,,1182.59,percent of total billed charges,,,95,,1445.9,percent of total billed charges,,,60,,913.2,percent of total billed charges,,913.2,1445.9,
ROOM/BED: Nursery Level II,23002,CDM,172,RC,,,,,Inpatient,,,1522,,,,80,,1217.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1182.59,percent of total billed charges,,,95,,1445.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1445.9,
ROOM/BED: Nursery Level III,33001,CDM,173,RC,,,,,Outpatient,,,1826,,,,80,,1460.8,percent of total billed charges,,,,85,1552.1,percent of total billed charges,,,77.7,,1418.8,percent of total billed charges,,,95,,1734.7,percent of total billed charges,,,60,,1095.6,percent of total billed charges,,1095.6,1734.7,
ROOM/BED: Nursery Level III,33001,CDM,173,RC,,,,,Inpatient,,,1826,,,,80,,1460.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1418.8,percent of total billed charges,,,95,,1734.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1734.7,
ROOM/BED: SB Skilled Private,42002,CDM,110,RC,,,,,Outpatient,,,1091,,,,80,,872.8,percent of total billed charges,,,,85,927.35,percent of total billed charges,,,77.7,,847.71,percent of total billed charges,,,95,,1036.45,percent of total billed charges,,,60,,654.6,percent of total billed charges,,654.6,1036.45,
ROOM/BED: SB Skilled Private,42002,CDM,110,RC,,,,,Inpatient,,,1091,,,,80,,872.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,847.71,percent of total billed charges,,,95,,1036.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1036.45,
ROOM/BED: SB Skilled Semi Private,42003,CDM,120,RC,,,,,Outpatient,,,1091,,,,80,,872.8,percent of total billed charges,,,,85,927.35,percent of total billed charges,,,77.7,,847.71,percent of total billed charges,,,95,,1036.45,percent of total billed charges,,,60,,654.6,percent of total billed charges,,654.6,1036.45,
ROOM/BED: SB Skilled Semi Private,42003,CDM,120,RC,,,,,Inpatient,,,1091,,,,80,,872.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,847.71,percent of total billed charges,,,95,,1036.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1036.45,
Urinary Catheter Type: -> Straight/Intermittent,51701,CDM,761,RC,51701,CPT,,,Outpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,50,72.45,fee schedule,,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,60,,157.06,percent of total billed charges,,157.06,248.68,
Urinary Catheter Type: -> Straight/Intermittent,51701,CDM,761,RC,51701,CPT,,,Inpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,248.68,
Urinary Catheter Type: -> Indwelling/Continuous,51702,CDM,761,RC,51702,CPT,,,Outpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,50,72.45,fee schedule,,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,60,,157.06,percent of total billed charges,,157.06,248.68,
Urinary Catheter Type: -> Indwelling/Continuous,51702,CDM,761,RC,51702,CPT,,,Inpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,248.68,
51798 Bladder Scanner,51798,CDM,761,RC,51798,CPT,,,Outpatient,,,95,,,,80,,76,percent of total billed charges,,,,50,33.84,fee schedule,,,77.7,,73.82,percent of total billed charges,,,95,,90.25,percent of total billed charges,,,60,,57,percent of total billed charges,,57,90.25,
Time Bladder Volume Instrument Performed,51798,CDM,761,RC,51798,CPT,,,Outpatient,,,95,,,,80,,76,percent of total billed charges,,,,50,33.84,fee schedule,,,77.7,,73.82,percent of total billed charges,,,95,,90.25,percent of total billed charges,,,60,,57,percent of total billed charges,,57,90.25,
51798 Bladder Scanner,51798,CDM,761,RC,51798,CPT,,,Inpatient,,,95,,,,80,,76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,73.82,percent of total billed charges,,,95,,90.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,90.25,
Time Bladder Volume Instrument Performed,51798,CDM,761,RC,51798,CPT,,,Inpatient,,,95,,,,80,,76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,73.82,percent of total billed charges,,,95,,90.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,90.25,
ROOM/BED: Nursery -  Baby rooming in,53009,CDM,170,RC,,,,,Outpatient,,,1142,,,,80,,913.6,percent of total billed charges,,,,85,970.7,percent of total billed charges,,,77.7,,887.33,percent of total billed charges,,,95,,1084.9,percent of total billed charges,,,60,,685.2,percent of total billed charges,,685.2,1084.9,
ROOM/BED: Nursery -  Baby rooming in,53009,CDM,170,RC,,,,,Inpatient,,,1142,,,,80,,913.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,887.33,percent of total billed charges,,,95,,1084.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1084.9,
ROOM/BED: SB Intermediate Semi Private,62000,CDM,120,RC,,,,,Outpatient,,,328,,,,80,,262.4,percent of total billed charges,,,,85,278.8,percent of total billed charges,,,77.7,,254.86,percent of total billed charges,,,95,,311.6,percent of total billed charges,,,60,,196.8,percent of total billed charges,,196.8,311.6,
ROOM/BED: SB Intermediate Semi Private,62000,CDM,120,RC,,,,,Inpatient,,,328,,,,80,,262.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,254.86,percent of total billed charges,,,95,,311.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,311.6,
ROOM/BED: SB Intermediate Private,62001,CDM,110,RC,,,,,Outpatient,,,328,,,,80,,262.4,percent of total billed charges,,,,85,278.8,percent of total billed charges,,,77.7,,254.86,percent of total billed charges,,,95,,311.6,percent of total billed charges,,,60,,196.8,percent of total billed charges,,196.8,311.6,
ROOM/BED: SB Intermediate Private,62001,CDM,110,RC,,,,,Inpatient,,,328,,,,80,,262.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,254.86,percent of total billed charges,,,95,,311.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,311.6,
US Pregnancy 1st Trimester (Amb),76805,CDM,402,RC,76805,CPT,,,Outpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,50,66.16,fee schedule,,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,60,,250.8,percent of total billed charges,,250.8,397.1,
US Pregnancy 2nd Trimester (Amb),76805,CDM,402,RC,76805,CPT,,,Outpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,50,66.16,fee schedule,,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,60,,250.8,percent of total billed charges,,250.8,397.1,
US Pregnancy 1st Trimester (Amb),76805,CDM,402,RC,76805,CPT,,,Inpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,397.1,
US Pregnancy 2nd Trimester (Amb),76805,CDM,402,RC,76805,CPT,,,Inpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,397.1,
UA non-automated without microscopy POC (81002),81002,CDM,300,RC,81002,CPT,,,Outpatient,,,29,,,,80,,23.2,percent of total billed charges,,,,50,5.18,fee schedule,,,77.7,,22.53,percent of total billed charges,,,95,,27.55,percent of total billed charges,,,60,,17.4,percent of total billed charges,,17.4,27.55,
UA non-automated without microscopy POC (81002),81002,CDM,300,RC,81002,CPT,,,Inpatient,,,29,,,,80,,23.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,22.53,percent of total billed charges,,,95,,27.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,27.55,
"UA automated, without microscopy POC (81003)",81003,CDM,300,RC,81003,CPT,,,Outpatient,,,25,,,,80,,20,percent of total billed charges,,,,50,4.6,fee schedule,,,77.7,,19.43,percent of total billed charges,,,95,,23.75,percent of total billed charges,,,60,,15,percent of total billed charges,,15,23.75,
"UA automated, without microscopy POC (81003)",81003,CDM,300,RC,81003,CPT,,,Inpatient,,,25,,,,80,,20,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.43,percent of total billed charges,,,95,,23.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,23.75,
Urine Pregnancy POC (81025),81025,CDM,300,RC,81025,CPT,,,Outpatient,,,37,,,,80,,29.6,percent of total billed charges,,,,50,13.57,fee schedule,,,77.7,,28.75,percent of total billed charges,,,95,,35.15,percent of total billed charges,,,60,,22.2,percent of total billed charges,,22.2,35.15,
Urine Pregnancy POC (81025),81025,CDM,300,RC,81025,CPT,,,Inpatient,,,37,,,,80,,29.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,28.75,percent of total billed charges,,,95,,35.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,35.15,
Hemoccult POC (82270),82270,CDM,300,RC,82270,CPT,,,Outpatient,,,26,,,,80,,20.8,percent of total billed charges,,,,50,6.21,fee schedule,,,77.7,,20.2,percent of total billed charges,,,95,,24.7,percent of total billed charges,,,60,,15.6,percent of total billed charges,,15.6,24.7,
Hemoccult POC (82270),82270,CDM,300,RC,82270,CPT,,,Inpatient,,,26,,,,80,,20.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,20.2,percent of total billed charges,,,95,,24.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,24.7,
Hemoccult POC (82272),82272,CDM,300,RC,82272,CPT,,,Outpatient,,,10,,,,80,,8,percent of total billed charges,,,,50,3.49,fee schedule,,,77.7,,7.77,percent of total billed charges,,,95,,9.5,percent of total billed charges,,,60,,6,percent of total billed charges,,6,9.5,
Hemoccult POC (82272),82272,CDM,300,RC,82272,CPT,,,Inpatient,,,10,,,,80,,8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.77,percent of total billed charges,,,95,,9.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.5,
Hemoglobin A1c POC (83036),83036,CDM,300,RC,83036,CPT,,,Outpatient,,,40,,,,80,,32,percent of total billed charges,,,,50,17.97,fee schedule,,,77.7,,31.08,percent of total billed charges,,,95,,38,percent of total billed charges,,,60,,24,percent of total billed charges,,24,38,
Hemoglobin A1c POC (83036),83036,CDM,300,RC,83036,CPT,,,Inpatient,,,40,,,,80,,32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,31.08,percent of total billed charges,,,95,,38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,38,
Hematocrit POC (85014),85014,CDM,300,RC,85014,CPT,,,Outpatient,,,10,,,,80,,8,percent of total billed charges,,,,50,4.46,fee schedule,,,77.7,,7.77,percent of total billed charges,,,95,,9.5,percent of total billed charges,,,60,,6,percent of total billed charges,,6,9.5,
Hematocrit POC (85014),85014,CDM,300,RC,85014,CPT,,,Inpatient,,,10,,,,80,,8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.77,percent of total billed charges,,,95,,9.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.5,
TB Skin Test POC (86580),86580,CDM,300,RC,86580,CPT,,,Outpatient,,,25,,,,80,,20,percent of total billed charges,,,,50,9.18,fee schedule,,,77.7,,19.43,percent of total billed charges,,,95,,23.75,percent of total billed charges,,,60,,15,percent of total billed charges,,15,23.75,
TB Skin Test POC (86580),86580,CDM,300,RC,86580,CPT,,,Inpatient,,,25,,,,80,,20,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.43,percent of total billed charges,,,95,,23.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,23.75,
KOH POC (87220),87220,CDM,300,RC,87220,CPT,,,Outpatient,,,25,,,,80,,20,percent of total billed charges,,,,50,9.03,fee schedule,,,77.7,,19.43,percent of total billed charges,,,95,,23.75,percent of total billed charges,,,60,,15,percent of total billed charges,,15,23.75,
KOH POC (87220),87220,CDM,300,RC,87220,CPT,,,Inpatient,,,25,,,,80,,20,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.43,percent of total billed charges,,,95,,23.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,23.75,
RSV POC (87420),87420,CDM,300,RC,87420,CPT,,,Outpatient,,,65,,,,80,,52,percent of total billed charges,,,,50,27.42,fee schedule,,,77.7,,50.51,percent of total billed charges,,,95,,61.75,percent of total billed charges,,,60,,39,percent of total billed charges,,39,61.75,
RSV POC (87420),87420,CDM,300,RC,87420,CPT,,,Inpatient,,,65,,,,80,,52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,50.51,percent of total billed charges,,,95,,61.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,61.75,
SARS COVID-19 Ag POC (87426),87426,CDM,300,RC,87426,CPT,,,Outpatient,,,97,,,,80,,77.6,percent of total billed charges,,,,50,27.42,fee schedule,,,77.7,,75.37,percent of total billed charges,,,95,,92.15,percent of total billed charges,,,60,,58.2,percent of total billed charges,,58.2,92.15,
SARS COVID-19 Ag POC (87426),87426,CDM,300,RC,87426,CPT,,,Inpatient,,,97,,,,80,,77.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,75.37,percent of total billed charges,,,95,,92.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,92.15,
SARS-COV-2 COVID-19  w/ Optic POC (87811),87811,CDM,300,RC,87811,CPT,,,Outpatient,,,55,,,,80,,44,percent of total billed charges,,,,50,22.05,fee schedule,,,77.7,,42.74,percent of total billed charges,,,95,,52.25,percent of total billed charges,,,60,,33,percent of total billed charges,,33,52.25,
SARS-COV-2 COVID-19  w/ Optic POC (87811),87811,CDM,300,RC,87811,CPT,,,Inpatient,,,55,,,,80,,44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,42.74,percent of total billed charges,,,95,,52.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,52.25,
Rapid Strep POC (87880),87880,CDM,300,RC,87880,CPT,,,Outpatient,,,59,,,,80,,47.2,percent of total billed charges,,,,50,27.42,fee schedule,,,77.7,,45.84,percent of total billed charges,,,95,,56.05,percent of total billed charges,,,60,,35.4,percent of total billed charges,,35.4,56.05,
Rapid Strep POC (87880),87880,CDM,300,RC,87880,CPT,,,Inpatient,,,59,,,,80,,47.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,45.84,percent of total billed charges,,,95,,56.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,56.05,
Admin Charge (Vaccine) -> 90460 Admin IM/SQ child w/ counseling,90460,CDM,761,RC,90460,CPT,,,Outpatient,,,24,,,,80,,19.2,percent of total billed charges,,,,85,20.4,percent of total billed charges,,,77.7,,18.65,percent of total billed charges,,,95,,22.8,percent of total billed charges,,,60,,14.4,percent of total billed charges,,14.4,22.8,
Admin Charge (Vaccine) -> 90460 Admin IM/SQ child w/ counseling,90460,CDM,761,RC,90460,CPT,,,Inpatient,,,24,,,,80,,19.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,18.65,percent of total billed charges,,,95,,22.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,22.8,
Admin Charge (Vaccine) -> 90461 Admin IM/SQ child addl w/ counseling,90461,CDM,761,RC,90461,CPT,,,Outpatient,,,24,,,,80,,19.2,percent of total billed charges,,,,85,20.4,percent of total billed charges,,,77.7,,18.65,percent of total billed charges,,,95,,22.8,percent of total billed charges,,,60,,14.4,percent of total billed charges,,14.4,22.8,
Admin Charge (Vaccine) -> 90461 Admin IM/SQ child addl w/ counseling,90461,CDM,761,RC,90461,CPT,,,Inpatient,,,24,,,,80,,19.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,18.65,percent of total billed charges,,,95,,22.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,22.8,
Admin Charge (Vaccine) -> 90471 Admin IM/SQ,90471,CDM,761,RC,90471,CPT,,,Outpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,50,4.04,fee schedule,,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,60,,157.06,percent of total billed charges,,157.06,248.68,
Admin Charge (Vaccine) -> 90471 Admin IM/SQ,90471,CDM,761,RC,90471,CPT,,,Inpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,248.68,
Admin Charge (Vaccine) -> 90472 Admin IM addl,90472,CDM,521,RC,90472,CPT,,,Outpatient,,,20,,,,80,,16,percent of total billed charges,,,,50,4.04,fee schedule,,,77.7,,15.54,percent of total billed charges,,,95,,19,percent of total billed charges,,,60,,12,percent of total billed charges,,12,19,
Admin Charge (Vaccine) -> 90472 Admin IM addl,90472,CDM,521,RC,90472,CPT,,,Inpatient,,,20,,,,80,,16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,15.54,percent of total billed charges,,,95,,19,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,19,
EKG POC,93000,CDM,730,RC,93000,CPT,,,Outpatient,,,245,,,,80,,196,percent of total billed charges,,,,85,208.25,percent of total billed charges,,,77.7,,190.37,percent of total billed charges,,,95,,232.75,percent of total billed charges,,,60,,147,percent of total billed charges,,147,232.75,
EKG POC,93000,CDM,730,RC,93000,CPT,,,Inpatient,,,245,,,,80,,196,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,190.37,percent of total billed charges,,,95,,232.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,232.75,
95115 Allergy Injection,95115,CDM,521,RC,95115,CPT,,,Outpatient,,,30,,,,80,,24,percent of total billed charges,,,,85,25.5,percent of total billed charges,,,77.7,,23.31,percent of total billed charges,,,95,,28.5,percent of total billed charges,,,60,,18,percent of total billed charges,,18,28.5,
95115 Allergy Injection,95115,CDM,521,RC,95115,CPT,,,Inpatient,,,30,,,,80,,24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,23.31,percent of total billed charges,,,95,,28.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,28.5,
95117 Allergy Injection 2 or more,95117,CDM,521,RC,95117,CPT,,,Outpatient,,,40,,,,80,,32,percent of total billed charges,,,,85,34,percent of total billed charges,,,77.7,,31.08,percent of total billed charges,,,95,,38,percent of total billed charges,,,60,,24,percent of total billed charges,,24,38,
95117 Allergy Injection 2 or more,95117,CDM,521,RC,95117,CPT,,,Inpatient,,,40,,,,80,,32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,31.08,percent of total billed charges,,,95,,38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,38,
TELFA 3X8,100504,CDM,270,RC,,,,,Outpatient,,,0.3,,,,80,,0.24,percent of total billed charges,,,,85,0.26,percent of total billed charges,,,77.7,,0.23,percent of total billed charges,,,95,,0.29,percent of total billed charges,,,60,,0.18,percent of total billed charges,,0.18,0.29,
TELFA 3X8,100504,CDM,270,RC,,,,,Inpatient,,,0.3,,,,80,,0.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.23,percent of total billed charges,,,95,,0.29,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,0.29,
OPSITE 5 1/2 X 10,100512,CDM,270,RC,,,,,Outpatient,,,33.1,,,,80,,26.48,percent of total billed charges,,,,85,28.14,percent of total billed charges,,,77.7,,25.72,percent of total billed charges,,,95,,31.45,percent of total billed charges,,,60,,19.86,percent of total billed charges,,19.86,31.45,
OPSITE 5 1/2 X 10,100512,CDM,270,RC,,,,,Inpatient,,,33.1,,,,80,,26.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,25.72,percent of total billed charges,,,95,,31.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,31.45,
"TONSIL SPONGE 7/8"" SINGLE STRING STERILE",100523,CDM,270,RC,,,,,Outpatient,,,50.8,,,,80,,40.64,percent of total billed charges,,,,85,43.18,percent of total billed charges,,,77.7,,39.47,percent of total billed charges,,,95,,48.26,percent of total billed charges,,,60,,30.48,percent of total billed charges,,30.48,48.26,
"TONSIL SPONGE 7/8"" SINGLE STRING STERILE",100523,CDM,270,RC,,,,,Inpatient,,,50.8,,,,80,,40.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,39.47,percent of total billed charges,,,95,,48.26,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,48.26,
ONE STEP SPLINT 3 X 12,100524,CDM,270,RC,,,,,Outpatient,,,14.6,,,,80,,11.68,percent of total billed charges,,,,85,12.41,percent of total billed charges,,,77.7,,11.34,percent of total billed charges,,,95,,13.87,percent of total billed charges,,,60,,8.76,percent of total billed charges,,8.76,13.87,
ONE STEP SPLINT 3 X 12,100524,CDM,270,RC,,,,,Inpatient,,,14.6,,,,80,,11.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.34,percent of total billed charges,,,95,,13.87,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.87,
SUTURE-O-VICRYL J958H OR,100526,CDM,270,RC,,,,,Outpatient,,,7.6,,,,80,,6.08,percent of total billed charges,,,,85,6.46,percent of total billed charges,,,77.7,,5.91,percent of total billed charges,,,95,,7.22,percent of total billed charges,,,60,,4.56,percent of total billed charges,,4.56,7.22,
SUTURE-O-VICRYL J958H OR,100526,CDM,270,RC,,,,,Inpatient,,,7.6,,,,80,,6.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.91,percent of total billed charges,,,95,,7.22,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.22,
SUTURE ETHG123H,100532,CDM,270,RC,,,,,Outpatient,,,9.1,,,,80,,7.28,percent of total billed charges,,,,85,7.74,percent of total billed charges,,,77.7,,7.07,percent of total billed charges,,,95,,8.65,percent of total billed charges,,,60,,5.46,percent of total billed charges,,5.46,8.65,
SUTURE ETHG123H,100532,CDM,270,RC,,,,,Inpatient,,,9.1,,,,80,,7.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.07,percent of total billed charges,,,95,,8.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,8.65,
ONE STEP SPLINT 3 X 35,100533,CDM,270,RC,,,,,Outpatient,,,32.9,,,,80,,26.32,percent of total billed charges,,,,85,27.97,percent of total billed charges,,,77.7,,25.56,percent of total billed charges,,,95,,31.26,percent of total billed charges,,,60,,19.74,percent of total billed charges,,19.74,31.26,
ONE STEP SPLINT 3 X 35,100533,CDM,270,RC,,,,,Inpatient,,,32.9,,,,80,,26.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,25.56,percent of total billed charges,,,95,,31.26,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,31.26,
ONE STEP SPLINT 5 X 30,100534,CDM,270,RC,,,,,Outpatient,,,68.2,,,,80,,54.56,percent of total billed charges,,,,85,57.97,percent of total billed charges,,,77.7,,52.99,percent of total billed charges,,,95,,64.79,percent of total billed charges,,,60,,40.92,percent of total billed charges,,40.92,64.79,
ONE STEP SPLINT 5 X 30,100534,CDM,270,RC,,,,,Inpatient,,,68.2,,,,80,,54.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,52.99,percent of total billed charges,,,95,,64.79,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,64.79,
SUTURE ETH852H,100549,CDM,270,RC,,,,,Outpatient,,,8.8,,,,80,,7.04,percent of total billed charges,,,,85,7.48,percent of total billed charges,,,77.7,,6.84,percent of total billed charges,,,95,,8.36,percent of total billed charges,,,60,,5.28,percent of total billed charges,,5.28,8.36,
SUTURE ETH852H,100549,CDM,270,RC,,,,,Inpatient,,,8.8,,,,80,,7.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.84,percent of total billed charges,,,95,,8.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,8.36,
KANGAROO PUMP SET,100569,CDM,270,RC,,,,,Outpatient,,,9.7,,,,80,,7.76,percent of total billed charges,,,,85,8.25,percent of total billed charges,,,77.7,,7.54,percent of total billed charges,,,95,,9.22,percent of total billed charges,,,60,,5.82,percent of total billed charges,,5.82,9.22,
KANGAROO PUMP SET,100569,CDM,270,RC,,,,,Inpatient,,,9.7,,,,80,,7.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.54,percent of total billed charges,,,95,,9.22,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.22,
SUTURE ETH 662G,100575,CDM,270,RC,,,,,Outpatient,,,7.5,,,,80,,6,percent of total billed charges,,,,85,6.38,percent of total billed charges,,,77.7,,5.83,percent of total billed charges,,,95,,7.13,percent of total billed charges,,,60,,4.5,percent of total billed charges,,4.5,7.13,
SUTURE ETH 662G,100575,CDM,270,RC,,,,,Inpatient,,,7.5,,,,80,,6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.83,percent of total billed charges,,,95,,7.13,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.13,
SUTURE 4-0 VICRYL  J422H,100594,CDM,270,RC,,,,,Outpatient,,,7.7,,,,80,,6.16,percent of total billed charges,,,,85,6.55,percent of total billed charges,,,77.7,,5.98,percent of total billed charges,,,95,,7.32,percent of total billed charges,,,60,,4.62,percent of total billed charges,,4.62,7.32,
SUTURE 4-0 VICRYL  J422H,100594,CDM,270,RC,,,,,Inpatient,,,7.7,,,,80,,6.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.98,percent of total billed charges,,,95,,7.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.32,
FOLEY CATH TUBE 8FR 3CC SILICONE,100596,CDM,270,RC,,,,,Outpatient,,,11.8,,,,80,,9.44,percent of total billed charges,,,,85,10.03,percent of total billed charges,,,77.7,,9.17,percent of total billed charges,,,95,,11.21,percent of total billed charges,,,60,,7.08,percent of total billed charges,,7.08,11.21,
FOLEY CATH TUBE 8FR 3CC SILICONE,100596,CDM,270,RC,,,,,Inpatient,,,11.8,,,,80,,9.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.17,percent of total billed charges,,,95,,11.21,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.21,
SUTURE 0-PROLENE 8412H,100599,CDM,270,RC,,,,,Outpatient,,,11.8,,,,80,,9.44,percent of total billed charges,,,,85,10.03,percent of total billed charges,,,77.7,,9.17,percent of total billed charges,,,95,,11.21,percent of total billed charges,,,60,,7.08,percent of total billed charges,,7.08,11.21,
SUTURE 0-PROLENE 8412H,100599,CDM,270,RC,,,,,Inpatient,,,11.8,,,,80,,9.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.17,percent of total billed charges,,,95,,11.21,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.21,
CAUTERY TIPOLISHER LG,100603,CDM,270,RC,,,,,Outpatient,,,1.6,,,,80,,1.28,percent of total billed charges,,,,85,1.36,percent of total billed charges,,,77.7,,1.24,percent of total billed charges,,,95,,1.52,percent of total billed charges,,,60,,0.96,percent of total billed charges,,0.96,1.52,
CAUTERY TIPOLISHER LG,100603,CDM,270,RC,,,,,Inpatient,,,1.6,,,,80,,1.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.24,percent of total billed charges,,,95,,1.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.52,
SUTURE ETHK833H,100604,CDM,270,RC,,,,,Outpatient,,,7.3,,,,80,,5.84,percent of total billed charges,,,,85,6.21,percent of total billed charges,,,77.7,,5.67,percent of total billed charges,,,95,,6.94,percent of total billed charges,,,60,,4.38,percent of total billed charges,,4.38,6.94,
SUTURE ETHK833H,100604,CDM,270,RC,,,,,Inpatient,,,7.3,,,,80,,5.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.67,percent of total billed charges,,,95,,6.94,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.94,
SUTURE 6-0 ETHILON 1665G,100606,CDM,270,RC,,,,,Outpatient,,,12.6,,,,80,,10.08,percent of total billed charges,,,,85,10.71,percent of total billed charges,,,77.7,,9.79,percent of total billed charges,,,95,,11.97,percent of total billed charges,,,60,,7.56,percent of total billed charges,,7.56,11.97,
SUTURE 6-0 ETHILON 1665G,100606,CDM,270,RC,,,,,Inpatient,,,12.6,,,,80,,10.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.79,percent of total billed charges,,,95,,11.97,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.97,
SUTURE ETH8423H,100607,CDM,270,RC,,,,,Outpatient,,,10.9,,,,80,,8.72,percent of total billed charges,,,,85,9.27,percent of total billed charges,,,77.7,,8.47,percent of total billed charges,,,95,,10.36,percent of total billed charges,,,60,,6.54,percent of total billed charges,,6.54,10.36,
SUTURE ETH8423H,100607,CDM,270,RC,,,,,Inpatient,,,10.9,,,,80,,8.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.47,percent of total billed charges,,,95,,10.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.36,
CHAR FLO W/SORBITAL,100610,CDM,270,RC,,,,,Outpatient,,,25.1,,,,80,,20.08,percent of total billed charges,,,,85,21.34,percent of total billed charges,,,77.7,,19.5,percent of total billed charges,,,95,,23.85,percent of total billed charges,,,60,,15.06,percent of total billed charges,,15.06,23.85,
CHAR FLO W/SORBITAL,100610,CDM,270,RC,,,,,Inpatient,,,25.1,,,,80,,20.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.5,percent of total billed charges,,,95,,23.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,23.85,
ELECTRODE 5MM BALL,100615,CDM,270,RC,,,,,Outpatient,,,31.8,,,,80,,25.44,percent of total billed charges,,,,85,27.03,percent of total billed charges,,,77.7,,24.71,percent of total billed charges,,,95,,30.21,percent of total billed charges,,,60,,19.08,percent of total billed charges,,19.08,30.21,
ELECTRODE 5MM BALL,100615,CDM,270,RC,,,,,Inpatient,,,31.8,,,,80,,25.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,24.71,percent of total billed charges,,,95,,30.21,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,30.21,
FOLEY CATH TUBE 20FR 5CC,100616,CDM,270,RC,,,,,Outpatient,,,6.4,,,,80,,5.12,percent of total billed charges,,,,85,5.44,percent of total billed charges,,,77.7,,4.97,percent of total billed charges,,,95,,6.08,percent of total billed charges,,,60,,3.84,percent of total billed charges,,3.84,6.08,
FOLEY CATH TUBE 20FR 5CC,100616,CDM,270,RC,,,,,Inpatient,,,6.4,,,,80,,5.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.97,percent of total billed charges,,,95,,6.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.08,
FOLEY CATH 24FR 5CC,100617,CDM,270,RC,,,,,Outpatient,,,11.6,,,,80,,9.28,percent of total billed charges,,,,85,9.86,percent of total billed charges,,,77.7,,9.01,percent of total billed charges,,,95,,11.02,percent of total billed charges,,,60,,6.96,percent of total billed charges,,6.96,11.02,
FOLEY CATH 24FR 5CC,100617,CDM,270,RC,,,,,Inpatient,,,11.6,,,,80,,9.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.01,percent of total billed charges,,,95,,11.02,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.02,
FOLEY CATH TUBE - 8 FR.,100618,CDM,270,RC,,,,,Outpatient,,,23.7,,,,80,,18.96,percent of total billed charges,,,,85,20.15,percent of total billed charges,,,77.7,,18.41,percent of total billed charges,,,95,,22.52,percent of total billed charges,,,60,,14.22,percent of total billed charges,,14.22,22.52,
FOLEY CATH TUBE - 8 FR.,100618,CDM,270,RC,,,,,Inpatient,,,23.7,,,,80,,18.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,18.41,percent of total billed charges,,,95,,22.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,22.52,
FOLEY CATH TUBE 10FR 3CC,100619,CDM,270,RC,,,,,Outpatient,,,23.7,,,,80,,18.96,percent of total billed charges,,,,85,20.15,percent of total billed charges,,,77.7,,18.41,percent of total billed charges,,,95,,22.52,percent of total billed charges,,,60,,14.22,percent of total billed charges,,14.22,22.52,
FOLEY CATH TUBE 10FR 3CC,100619,CDM,270,RC,,,,,Inpatient,,,23.7,,,,80,,18.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,18.41,percent of total billed charges,,,95,,22.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,22.52,
FOLEY CATH TUBE 12FR 5CC,100620,CDM,270,RC,,,,,Outpatient,,,11.7,,,,80,,9.36,percent of total billed charges,,,,85,9.95,percent of total billed charges,,,77.7,,9.09,percent of total billed charges,,,95,,11.12,percent of total billed charges,,,60,,7.02,percent of total billed charges,,7.02,11.12,
FOLEY CATH TUBE 12FR 5CC,100620,CDM,270,RC,,,,,Inpatient,,,11.7,,,,80,,9.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.09,percent of total billed charges,,,95,,11.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.12,
OPSITE 4x51/2,100622,CDM,270,RC,,,,,Outpatient,,,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
OPSITE 4x51/2,100622,CDM,270,RC,,,,,Inpatient,,,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
ABDOMINAL BINDER-SM/MED,100625,CDM,270,RC,,,,,Outpatient,,,19.7,,,,80,,15.76,percent of total billed charges,,,,85,16.75,percent of total billed charges,,,77.7,,15.31,percent of total billed charges,,,95,,18.72,percent of total billed charges,,,60,,11.82,percent of total billed charges,,11.82,18.72,
ABDOMINAL BINDER-SM/MED,100625,CDM,270,RC,,,,,Inpatient,,,19.7,,,,80,,15.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,15.31,percent of total billed charges,,,95,,18.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,18.72,
ABDOMINAL BINDER-MED/LG,100626,CDM,270,RC,,,,,Outpatient,,,21.1,,,,80,,16.88,percent of total billed charges,,,,85,17.94,percent of total billed charges,,,77.7,,16.39,percent of total billed charges,,,95,,20.05,percent of total billed charges,,,60,,12.66,percent of total billed charges,,12.66,20.05,
ABDOMINAL BINDER-MED/LG,100626,CDM,270,RC,,,,,Inpatient,,,21.1,,,,80,,16.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,16.39,percent of total billed charges,,,95,,20.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,20.05,
ABDOMINAL BINDER-XL,100627,CDM,270,RC,,,,,Outpatient,,,26.7,,,,80,,21.36,percent of total billed charges,,,,85,22.7,percent of total billed charges,,,77.7,,20.75,percent of total billed charges,,,95,,25.37,percent of total billed charges,,,60,,16.02,percent of total billed charges,,16.02,25.37,
ABDOMINAL BINDER-XL,100627,CDM,270,RC,,,,,Inpatient,,,26.7,,,,80,,21.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,20.75,percent of total billed charges,,,95,,25.37,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,25.37,
VASELINE GAUZE 3X9 CURAD,100628,CDM,270,RC,,,,,Outpatient,,,1.3,,,,80,,1.04,percent of total billed charges,,,,85,1.11,percent of total billed charges,,,77.7,,1.01,percent of total billed charges,,,95,,1.24,percent of total billed charges,,,60,,0.78,percent of total billed charges,,0.78,1.24,
VASELINE GAUZE 3X9 CURAD,100628,CDM,270,RC,,,,,Inpatient,,,1.3,,,,80,,1.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.01,percent of total billed charges,,,95,,1.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.24,
NEEDLE SPINAL 25 X 1 1/2,100629,CDM,270,RC,,,,,Outpatient,,,28.3,,,,80,,22.64,percent of total billed charges,,,,85,24.06,percent of total billed charges,,,77.7,,21.99,percent of total billed charges,,,95,,26.89,percent of total billed charges,,,60,,16.98,percent of total billed charges,,16.98,26.89,
NEEDLE SPINAL 25 X 1 1/2,100629,CDM,270,RC,,,,,Inpatient,,,28.3,,,,80,,22.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,21.99,percent of total billed charges,,,95,,26.89,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,26.89,
Adult Ambu Bag,100630,CDM,270,RC,,,,,Outpatient,,,26.9,,,,80,,21.52,percent of total billed charges,,,,85,22.87,percent of total billed charges,,,77.7,,20.9,percent of total billed charges,,,95,,25.56,percent of total billed charges,,,60,,16.14,percent of total billed charges,,16.14,25.56,
Adult Ambu Bag,100630,CDM,270,RC,,,,,Inpatient,,,26.9,,,,80,,21.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,20.9,percent of total billed charges,,,95,,25.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,25.56,
CAUTERY TIP LONG FLAT BLADE AARON,100631,CDM,270,RC,,,,,Outpatient,,,12.4,,,,80,,9.92,percent of total billed charges,,,,85,10.54,percent of total billed charges,,,77.7,,9.63,percent of total billed charges,,,95,,11.78,percent of total billed charges,,,60,,7.44,percent of total billed charges,,7.44,11.78,
CAUTERY TIP LONG FLAT BLADE AARON,100631,CDM,270,RC,,,,,Inpatient,,,12.4,,,,80,,9.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.63,percent of total billed charges,,,95,,11.78,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.78,
STOMACH TUBE NG 12 FR,100634,CDM,270,RC,,,,,Outpatient,,,5.5,,,,80,,4.4,percent of total billed charges,,,,85,4.68,percent of total billed charges,,,77.7,,4.27,percent of total billed charges,,,95,,5.23,percent of total billed charges,,,60,,3.3,percent of total billed charges,,3.3,5.23,
STOMACH TUBE NG 12 FR,100634,CDM,270,RC,,,,,Inpatient,,,5.5,,,,80,,4.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.27,percent of total billed charges,,,95,,5.23,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.23,
STOMACH TUBE NG 14 FR,100635,CDM,270,RC,,,,,Outpatient,,,3.2,,,,80,,2.56,percent of total billed charges,,,,85,2.72,percent of total billed charges,,,77.7,,2.49,percent of total billed charges,,,95,,3.04,percent of total billed charges,,,60,,1.92,percent of total billed charges,,1.92,3.04,
STOMACH TUBE NG 14 FR,100635,CDM,270,RC,,,,,Inpatient,,,3.2,,,,80,,2.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.49,percent of total billed charges,,,95,,3.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.04,
CHOLANGIO CATHETER RANFAC,100648,CDM,270,RC,,,,,Outpatient,,,98.3,,,,80,,78.64,percent of total billed charges,,,,85,83.56,percent of total billed charges,,,77.7,,76.38,percent of total billed charges,,,95,,93.39,percent of total billed charges,,,60,,58.98,percent of total billed charges,,58.98,93.39,
CHOLANGIO CATHETER RANFAC,100648,CDM,270,RC,,,,,Inpatient,,,98.3,,,,80,,78.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,76.38,percent of total billed charges,,,95,,93.39,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,93.39,
T TUBE DRAIN 14 FR,100650,CDM,270,RC,,,,,Outpatient,,,25.6,,,,80,,20.48,percent of total billed charges,,,,85,21.76,percent of total billed charges,,,77.7,,19.89,percent of total billed charges,,,95,,24.32,percent of total billed charges,,,60,,15.36,percent of total billed charges,,15.36,24.32,
T TUBE DRAIN 14 FR,100650,CDM,270,RC,,,,,Inpatient,,,25.6,,,,80,,20.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.89,percent of total billed charges,,,95,,24.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,24.32,
T TUBE DRAIN 12 FR,100651,CDM,270,RC,,,,,Outpatient,,,25.6,,,,80,,20.48,percent of total billed charges,,,,85,21.76,percent of total billed charges,,,77.7,,19.89,percent of total billed charges,,,95,,24.32,percent of total billed charges,,,60,,15.36,percent of total billed charges,,15.36,24.32,
T TUBE DRAIN 12 FR,100651,CDM,270,RC,,,,,Inpatient,,,25.6,,,,80,,20.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.89,percent of total billed charges,,,95,,24.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,24.32,
T TUBE DRAIN 10 FR,100652,CDM,270,RC,,,,,Outpatient,,,25.6,,,,80,,20.48,percent of total billed charges,,,,85,21.76,percent of total billed charges,,,77.7,,19.89,percent of total billed charges,,,95,,24.32,percent of total billed charges,,,60,,15.36,percent of total billed charges,,15.36,24.32,
T TUBE DRAIN 10 FR,100652,CDM,270,RC,,,,,Inpatient,,,25.6,,,,80,,20.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.89,percent of total billed charges,,,95,,24.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,24.32,
BILE DRAIN BAG,100653,CDM,270,RC,,,,,Outpatient,,,26.4,,,,80,,21.12,percent of total billed charges,,,,85,22.44,percent of total billed charges,,,77.7,,20.51,percent of total billed charges,,,95,,25.08,percent of total billed charges,,,60,,15.84,percent of total billed charges,,15.84,25.08,
BILE DRAIN BAG,100653,CDM,270,RC,,,,,Inpatient,,,26.4,,,,80,,21.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,20.51,percent of total billed charges,,,95,,25.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,25.08,
EXTENSION SET 3 PORT MEDIFOLD,100657,CDM,270,RC,,,,,Outpatient,,,15.3,,,,80,,12.24,percent of total billed charges,,,,85,13.01,percent of total billed charges,,,77.7,,11.89,percent of total billed charges,,,95,,14.54,percent of total billed charges,,,60,,9.18,percent of total billed charges,,9.18,14.54,
EXTENSION SET 3 PORT MEDIFOLD,100657,CDM,270,RC,,,,,Inpatient,,,15.3,,,,80,,12.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.89,percent of total billed charges,,,95,,14.54,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,14.54,
"UNNA BOOT 4""",100658,CDM,270,RC,,,,,Outpatient,,,18.9,,,,80,,15.12,percent of total billed charges,,,,85,16.07,percent of total billed charges,,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,60,,11.34,percent of total billed charges,,11.34,17.96,
"UNNA BOOT 4""",100658,CDM,270,RC,,,,,Inpatient,,,18.9,,,,80,,15.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.96,
HEAVY DRAIN PACK,100665,CDM,270,RC,,,,,Outpatient,,,4.8,,,,80,,3.84,percent of total billed charges,,,,85,4.08,percent of total billed charges,,,77.7,,3.73,percent of total billed charges,,,95,,4.56,percent of total billed charges,,,60,,2.88,percent of total billed charges,,2.88,4.56,
HEAVY DRAIN PACK,100665,CDM,270,RC,,,,,Inpatient,,,4.8,,,,80,,3.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.73,percent of total billed charges,,,95,,4.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.56,
FALOPE RING KIT,100668,CDM,270,RC,,,,,Outpatient,,,410.6,,,,80,,328.48,percent of total billed charges,,,,85,349.01,percent of total billed charges,,,77.7,,319.04,percent of total billed charges,,,95,,390.07,percent of total billed charges,,,60,,246.36,percent of total billed charges,,246.36,390.07,
FALOPE RING KIT,100668,CDM,270,RC,,,,,Inpatient,,,410.6,,,,80,,328.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,319.04,percent of total billed charges,,,95,,390.07,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,390.07,
PEANUT SPONGES,100669,CDM,270,RC,,,,,Outpatient,,,4.8,,,,80,,3.84,percent of total billed charges,,,,85,4.08,percent of total billed charges,,,77.7,,3.73,percent of total billed charges,,,95,,4.56,percent of total billed charges,,,60,,2.88,percent of total billed charges,,2.88,4.56,
PEANUT SPONGES,100669,CDM,270,RC,,,,,Inpatient,,,4.8,,,,80,,3.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.73,percent of total billed charges,,,95,,4.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.56,
THOMAS TUBE HOLDER ADULT,100670,CDM,270,RC,,,,,Outpatient,,,11.7,,,,80,,9.36,percent of total billed charges,,,,85,9.95,percent of total billed charges,,,77.7,,9.09,percent of total billed charges,,,95,,11.12,percent of total billed charges,,,60,,7.02,percent of total billed charges,,7.02,11.12,
THOMAS TUBE HOLDER ADULT,100670,CDM,270,RC,,,,,Inpatient,,,11.7,,,,80,,9.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.09,percent of total billed charges,,,95,,11.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.12,
THOMAS TUBE HOLDER PED,100671,CDM,270,RC,,,,,Outpatient,,,11.4,,,,80,,9.12,percent of total billed charges,,,,85,9.69,percent of total billed charges,,,77.7,,8.86,percent of total billed charges,,,95,,10.83,percent of total billed charges,,,60,,6.84,percent of total billed charges,,6.84,10.83,
THOMAS TUBE HOLDER PED,100671,CDM,270,RC,,,,,Inpatient,,,11.4,,,,80,,9.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.86,percent of total billed charges,,,95,,10.83,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.83,
FOLEY CATH TUBE 20FR 30CC,100675,CDM,270,RC,,,,,Outpatient,,,6.4,,,,80,,5.12,percent of total billed charges,,,,85,5.44,percent of total billed charges,,,77.7,,4.97,percent of total billed charges,,,95,,6.08,percent of total billed charges,,,60,,3.84,percent of total billed charges,,3.84,6.08,
FOLEY CATH TUBE 20FR 30CC,100675,CDM,270,RC,,,,,Inpatient,,,6.4,,,,80,,5.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.97,percent of total billed charges,,,95,,6.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.08,
"OSTOMY POUCH 2 3/4"" HOLLISTER",100683,CDM,274,RC,A4425,HCPCS,,,Outpatient,,,3.8,,,,80,,3.04,percent of total billed charges,,,,50,3.17,fee schedule,,,77.7,,2.95,percent of total billed charges,,,95,,3.61,percent of total billed charges,,,60,,2.28,percent of total billed charges,,2.28,3.61,
"OSTOMY POUCH 2 3/4"" HOLLISTER",100683,CDM,274,RC,A4425,HCPCS,,,Inpatient,,,3.8,,,,80,,3.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.95,percent of total billed charges,,,95,,3.61,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.61,
OSTOMY CENTER PT LOCK  2 3/4 HOLLISTER,100684,CDM,274,RC,A4415,HCPCS,,,Outpatient,,,4.7,,,,80,,3.76,percent of total billed charges,,,,50,4.34,fee schedule,,,77.7,,3.65,percent of total billed charges,,,95,,4.47,percent of total billed charges,,,60,,2.82,percent of total billed charges,,2.82,4.47,
OSTOMY CENTER PT LOCK  2 3/4 HOLLISTER,100684,CDM,274,RC,A4415,HCPCS,,,Inpatient,,,4.7,,,,80,,3.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.65,percent of total billed charges,,,95,,4.47,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.47,
IRRIGATION SOLUTION SC 100 BTL SNAP OFF,100685,CDM,270,RC,,,,,Outpatient,,,3.8,,,,80,,3.04,percent of total billed charges,,,,85,3.23,percent of total billed charges,,,77.7,,2.95,percent of total billed charges,,,95,,3.61,percent of total billed charges,,,60,,2.28,percent of total billed charges,,2.28,3.61,
IRRIGATION SOLUTION SC 100 BTL SNAP OFF,100685,CDM,270,RC,,,,,Inpatient,,,3.8,,,,80,,3.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.95,percent of total billed charges,,,95,,3.61,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.61,
NEBULIZER HEART,100686,CDM,270,RC,,,,,Outpatient,,,60.4,,,,80,,48.32,percent of total billed charges,,,,85,51.34,percent of total billed charges,,,77.7,,46.93,percent of total billed charges,,,95,,57.38,percent of total billed charges,,,60,,36.24,percent of total billed charges,,36.24,57.38,
NEBULIZER HEART,100686,CDM,270,RC,,,,,Inpatient,,,60.4,,,,80,,48.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,46.93,percent of total billed charges,,,95,,57.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,57.38,
FOLEY CATH 16FR 5 CC SILICONE LF,100688,CDM,270,RC,,,,,Outpatient,,,12.3,,,,80,,9.84,percent of total billed charges,,,,85,10.46,percent of total billed charges,,,77.7,,9.56,percent of total billed charges,,,95,,11.69,percent of total billed charges,,,60,,7.38,percent of total billed charges,,7.38,11.69,
FOLEY CATH 16FR 5 CC SILICONE LF,100688,CDM,270,RC,,,,,Inpatient,,,12.3,,,,80,,9.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.56,percent of total billed charges,,,95,,11.69,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.69,
DAVOL CATH 14 FR VINYL,100692,CDM,270,RC,,,,,Outpatient,,,24.9,,,,80,,19.92,percent of total billed charges,,,,85,21.17,percent of total billed charges,,,77.7,,19.35,percent of total billed charges,,,95,,23.66,percent of total billed charges,,,60,,14.94,percent of total billed charges,,14.94,23.66,
DAVOL CATH 14 FR VINYL,100692,CDM,270,RC,,,,,Inpatient,,,24.9,,,,80,,19.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.35,percent of total billed charges,,,95,,23.66,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,23.66,
AQUACEL DRESSING 4 X 5 CONVATEC,100698,CDM,270,RC,,,,,Outpatient,,,13.3,,,,80,,10.64,percent of total billed charges,,,,85,11.31,percent of total billed charges,,,77.7,,10.33,percent of total billed charges,,,95,,12.64,percent of total billed charges,,,60,,7.98,percent of total billed charges,,7.98,12.64,
AQUACEL DRESSING 4 X 5 CONVATEC,100698,CDM,270,RC,,,,,Inpatient,,,13.3,,,,80,,10.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.33,percent of total billed charges,,,95,,12.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,12.64,
CERV COLLAR BABY STIFNECK,100701,CDM,274,RC,L0140,HCPCS,,,Outpatient,,,39.8,,,,80,,31.84,percent of total billed charges,,,,85,33.83,percent of total billed charges,,,77.7,,30.92,percent of total billed charges,,,95,,37.81,percent of total billed charges,,,60,,23.88,percent of total billed charges,,23.88,37.81,
CERV COLLAR BABY STIFNECK,100701,CDM,274,RC,L0140,HCPCS,,,Inpatient,,,39.8,,,,80,,31.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,30.92,percent of total billed charges,,,95,,37.81,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,37.81,
CERV COLLAR PED STIFNECK,100702,CDM,274,RC,L0140,HCPCS,,,Outpatient,,,42.8,,,,80,,34.24,percent of total billed charges,,,,85,36.38,percent of total billed charges,,,77.7,,33.26,percent of total billed charges,,,95,,40.66,percent of total billed charges,,,60,,25.68,percent of total billed charges,,25.68,40.66,
CERV COLLAR PED STIFNECK,100702,CDM,274,RC,L0140,HCPCS,,,Inpatient,,,42.8,,,,80,,34.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,33.26,percent of total billed charges,,,95,,40.66,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,40.66,
CERV COLLAR NO-NECK STIFNECK,100703,CDM,274,RC,L0140,HCPCS,,,Outpatient,,,31.7,,,,80,,25.36,percent of total billed charges,,,,85,26.95,percent of total billed charges,,,77.7,,24.63,percent of total billed charges,,,95,,30.12,percent of total billed charges,,,60,,19.02,percent of total billed charges,,19.02,30.12,
CERV COLLAR NO-NECK STIFNECK,100703,CDM,274,RC,L0140,HCPCS,,,Inpatient,,,31.7,,,,80,,25.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,24.63,percent of total billed charges,,,95,,30.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,30.12,
CERV COLLAR SHORT STIFNECK,100704,CDM,274,RC,L0140,HCPCS,,,Outpatient,,,53.6,,,,80,,42.88,percent of total billed charges,,,,85,45.56,percent of total billed charges,,,77.7,,41.65,percent of total billed charges,,,95,,50.92,percent of total billed charges,,,60,,32.16,percent of total billed charges,,32.16,50.92,
CERV COLLAR SHORT STIFNECK,100704,CDM,274,RC,L0140,HCPCS,,,Inpatient,,,53.6,,,,80,,42.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,41.65,percent of total billed charges,,,95,,50.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,50.92,
CERV COLLAR REGULAR STIFNECK,100705,CDM,274,RC,L0140,HCPCS,,,Outpatient,,,32.3,,,,80,,25.84,percent of total billed charges,,,,85,27.46,percent of total billed charges,,,77.7,,25.1,percent of total billed charges,,,95,,30.69,percent of total billed charges,,,60,,19.38,percent of total billed charges,,19.38,30.69,
CERV COLLAR REGULAR STIFNECK,100705,CDM,274,RC,L0140,HCPCS,,,Inpatient,,,32.3,,,,80,,25.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,25.1,percent of total billed charges,,,95,,30.69,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,30.69,
CERV COLLAR TALL STIFNECK,100706,CDM,274,RC,L0140,HCPCS,,,Outpatient,,,38.1,,,,80,,30.48,percent of total billed charges,,,,85,32.39,percent of total billed charges,,,77.7,,29.6,percent of total billed charges,,,95,,36.2,percent of total billed charges,,,60,,22.86,percent of total billed charges,,22.86,36.2,
CERV COLLAR TALL STIFNECK,100706,CDM,274,RC,L0140,HCPCS,,,Inpatient,,,38.1,,,,80,,30.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,29.6,percent of total billed charges,,,95,,36.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,36.2,
FOLEY CATH TUBE 16FR 30CC,100707,CDM,270,RC,,,,,Outpatient,,,6.4,,,,80,,5.12,percent of total billed charges,,,,85,5.44,percent of total billed charges,,,77.7,,4.97,percent of total billed charges,,,95,,6.08,percent of total billed charges,,,60,,3.84,percent of total billed charges,,3.84,6.08,
FOLEY CATH TUBE 16FR 30CC,100707,CDM,270,RC,,,,,Inpatient,,,6.4,,,,80,,5.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.97,percent of total billed charges,,,95,,6.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.08,
FOLEY CATH 18FR 30CC,100708,CDM,270,RC,,,,,Outpatient,,,6.4,,,,80,,5.12,percent of total billed charges,,,,85,5.44,percent of total billed charges,,,77.7,,4.97,percent of total billed charges,,,95,,6.08,percent of total billed charges,,,60,,3.84,percent of total billed charges,,3.84,6.08,
FOLEY CATH 18FR 30CC,100708,CDM,270,RC,,,,,Inpatient,,,6.4,,,,80,,5.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.97,percent of total billed charges,,,95,,6.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.08,
SKIN MARKER W/RULER,100710,CDM,270,RC,,,,,Outpatient,,,5.8,,,,80,,4.64,percent of total billed charges,,,,85,4.93,percent of total billed charges,,,77.7,,4.51,percent of total billed charges,,,95,,5.51,percent of total billed charges,,,60,,3.48,percent of total billed charges,,3.48,5.51,
SKIN MARKER W/RULER,100710,CDM,270,RC,,,,,Inpatient,,,5.8,,,,80,,4.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.51,percent of total billed charges,,,95,,5.51,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.51,
"UMBILICAL TAPE 1/8 X 30""",100717,CDM,270,RC,,,,,Outpatient,,,6.1,,,,80,,4.88,percent of total billed charges,,,,85,5.19,percent of total billed charges,,,77.7,,4.74,percent of total billed charges,,,95,,5.8,percent of total billed charges,,,60,,3.66,percent of total billed charges,,3.66,5.8,
"UMBILICAL TAPE 1/8 X 30""",100717,CDM,270,RC,,,,,Inpatient,,,6.1,,,,80,,4.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.74,percent of total billed charges,,,95,,5.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.8,
"PACKING GAUZE 1/2"" PLAIN",100718,CDM,270,RC,,,,,Outpatient,,,6.2,,,,80,,4.96,percent of total billed charges,,,,85,5.27,percent of total billed charges,,,77.7,,4.82,percent of total billed charges,,,95,,5.89,percent of total billed charges,,,60,,3.72,percent of total billed charges,,3.72,5.89,
"PACKING GAUZE 1/2"" PLAIN",100718,CDM,270,RC,,,,,Inpatient,,,6.2,,,,80,,4.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.82,percent of total billed charges,,,95,,5.89,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.89,
"PACKING GAUZE 1/4"" IODOFORM",100719,CDM,270,RC,,,,,Outpatient,,,7.5,,,,80,,6,percent of total billed charges,,,,85,6.38,percent of total billed charges,,,77.7,,5.83,percent of total billed charges,,,95,,7.13,percent of total billed charges,,,60,,4.5,percent of total billed charges,,4.5,7.13,
"PACKING GAUZE 1/4"" IODOFORM",100719,CDM,270,RC,,,,,Inpatient,,,7.5,,,,80,,6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.83,percent of total billed charges,,,95,,7.13,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.13,
ENDOCATCH AUTOSUTURE,100725,CDM,270,RC,,,,,Outpatient,,,698.9,,,,80,,559.12,percent of total billed charges,,,,85,594.07,percent of total billed charges,,,77.7,,543.05,percent of total billed charges,,,95,,663.96,percent of total billed charges,,,60,,419.34,percent of total billed charges,,419.34,663.96,
ENDOCATCH AUTOSUTURE,100725,CDM,270,RC,,,,,Inpatient,,,698.9,,,,80,,559.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,543.05,percent of total billed charges,,,95,,663.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,663.96,
ENDO MINI SHEARS,100726,CDM,270,RC,,,,,Outpatient,,,786.8,,,,80,,629.44,percent of total billed charges,,,,85,668.78,percent of total billed charges,,,77.7,,611.34,percent of total billed charges,,,95,,747.46,percent of total billed charges,,,60,,472.08,percent of total billed charges,,472.08,747.46,
ENDO MINI SHEARS,100726,CDM,270,RC,,,,,Inpatient,,,786.8,,,,80,,629.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,611.34,percent of total billed charges,,,95,,747.46,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,747.46,
STAPLER TA55 3.5 MULTIFIRE,100727,CDM,270,RC,,,,,Outpatient,,,354.2,,,,80,,283.36,percent of total billed charges,,,,85,301.07,percent of total billed charges,,,77.7,,275.21,percent of total billed charges,,,95,,336.49,percent of total billed charges,,,60,,212.52,percent of total billed charges,,212.52,336.49,
STAPLER TA55 3.5 MULTIFIRE,100727,CDM,270,RC,,,,,Inpatient,,,354.2,,,,80,,283.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,275.21,percent of total billed charges,,,95,,336.49,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,336.49,
ENDO SHEARS ETHICON,100728,CDM,270,RC,,,,,Outpatient,,,806.2,,,,80,,644.96,percent of total billed charges,,,,85,685.27,percent of total billed charges,,,77.7,,626.42,percent of total billed charges,,,95,,765.89,percent of total billed charges,,,60,,483.72,percent of total billed charges,,483.72,765.89,
ENDO SHEARS ETHICON,100728,CDM,270,RC,,,,,Inpatient,,,806.2,,,,80,,644.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,626.42,percent of total billed charges,,,95,,765.89,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,765.89,
TROCAR 10-12MM BLADELESS ETHICON,100729,CDM,270,RC,,,,,Outpatient,,,360.1,,,,80,,288.08,percent of total billed charges,,,,85,306.09,percent of total billed charges,,,77.7,,279.8,percent of total billed charges,,,95,,342.1,percent of total billed charges,,,60,,216.06,percent of total billed charges,,216.06,342.1,
TROCAR 10-12MM BLADELESS ETHICON,100729,CDM,270,RC,,,,,Inpatient,,,360.1,,,,80,,288.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,279.8,percent of total billed charges,,,95,,342.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,342.1,
TROCAR 5MM BLADELESS ETHICON,100730,CDM,270,RC,,,,,Outpatient,,,78.8,,,,80,,63.04,percent of total billed charges,,,,85,66.98,percent of total billed charges,,,77.7,,61.23,percent of total billed charges,,,95,,74.86,percent of total billed charges,,,60,,47.28,percent of total billed charges,,47.28,74.86,
TROCAR 5MM BLADELESS ETHICON,100730,CDM,270,RC,,,,,Inpatient,,,78.8,,,,80,,63.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,61.23,percent of total billed charges,,,95,,74.86,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,74.86,
TROCAR SLEEVE 5MM ETHICON,100731,CDM,270,RC,,,,,Outpatient,,,114.8,,,,80,,91.84,percent of total billed charges,,,,85,97.58,percent of total billed charges,,,77.7,,89.2,percent of total billed charges,,,95,,109.06,percent of total billed charges,,,60,,68.88,percent of total billed charges,,68.88,109.06,
TROCAR SLEEVE 5MM ETHICON,100731,CDM,270,RC,,,,,Inpatient,,,114.8,,,,80,,91.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,89.2,percent of total billed charges,,,95,,109.06,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,109.06,
REDUCER CAP 5-12MM ETHICON,100732,CDM,270,RC,,,,,Outpatient,,,19.3,,,,80,,15.44,percent of total billed charges,,,,85,16.41,percent of total billed charges,,,77.7,,15,percent of total billed charges,,,95,,18.34,percent of total billed charges,,,60,,11.58,percent of total billed charges,,11.58,18.34,
REDUCER CAP 5-12MM ETHICON,100732,CDM,270,RC,,,,,Inpatient,,,19.3,,,,80,,15.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,15,percent of total billed charges,,,95,,18.34,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,18.34,
ENDO POUCH RETRIEVER ETHICON,100733,CDM,270,RC,,,,,Outpatient,,,192.5,,,,80,,154,percent of total billed charges,,,,85,163.63,percent of total billed charges,,,77.7,,149.57,percent of total billed charges,,,95,,182.88,percent of total billed charges,,,60,,115.5,percent of total billed charges,,115.5,182.88,
ENDO POUCH RETRIEVER ETHICON,100733,CDM,270,RC,,,,,Inpatient,,,192.5,,,,80,,154,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,149.57,percent of total billed charges,,,95,,182.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,182.88,
ENDO CLIP ETHICON,100734,CDM,270,RC,,,,,Outpatient,,,335.6,,,,80,,268.48,percent of total billed charges,,,,85,285.26,percent of total billed charges,,,77.7,,260.76,percent of total billed charges,,,95,,318.82,percent of total billed charges,,,60,,201.36,percent of total billed charges,,201.36,318.82,
ENDO CLIP ETHICON,100734,CDM,270,RC,,,,,Inpatient,,,335.6,,,,80,,268.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,260.76,percent of total billed charges,,,95,,318.82,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,318.82,
LINEAR CUTTER/STAPLER 75MM ETH,100735,CDM,270,RC,,,,,Outpatient,,,961.9,,,,80,,769.52,percent of total billed charges,,,,85,817.62,percent of total billed charges,,,77.7,,747.4,percent of total billed charges,,,95,,913.81,percent of total billed charges,,,60,,577.14,percent of total billed charges,,577.14,913.81,
LINEAR CUTTER/STAPLER 75MM ETH,100735,CDM,270,RC,,,,,Inpatient,,,961.9,,,,80,,769.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,747.4,percent of total billed charges,,,95,,913.81,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,913.81,
LINEAR CUTTER RELOAD  75MM ETH,100736,CDM,270,RC,,,,,Outpatient,,,478.7,,,,80,,382.96,percent of total billed charges,,,,85,406.9,percent of total billed charges,,,77.7,,371.95,percent of total billed charges,,,95,,454.77,percent of total billed charges,,,60,,287.22,percent of total billed charges,,287.22,454.77,
LINEAR CUTTER RELOAD  75MM ETH,100736,CDM,270,RC,,,,,Inpatient,,,478.7,,,,80,,382.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,371.95,percent of total billed charges,,,95,,454.77,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,454.77,
LINEAR STAPLER 60MM ETHICON,100737,CDM,270,RC,,,,,Outpatient,,,587.1,,,,80,,469.68,percent of total billed charges,,,,85,499.04,percent of total billed charges,,,77.7,,456.18,percent of total billed charges,,,95,,557.75,percent of total billed charges,,,60,,352.26,percent of total billed charges,,352.26,557.75,
LINEAR STAPLER 60MM ETHICON,100737,CDM,270,RC,,,,,Inpatient,,,587.1,,,,80,,469.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,456.18,percent of total billed charges,,,95,,557.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,557.75,
LINEAR STAPLER RELOAD 60MM ETH,100738,CDM,270,RC,,,,,Outpatient,,,293.5,,,,80,,234.8,percent of total billed charges,,,,85,249.48,percent of total billed charges,,,77.7,,228.05,percent of total billed charges,,,95,,278.83,percent of total billed charges,,,60,,176.1,percent of total billed charges,,176.1,278.83,
LINEAR STAPLER RELOAD 60MM ETH,100738,CDM,270,RC,,,,,Inpatient,,,293.5,,,,80,,234.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,228.05,percent of total billed charges,,,95,,278.83,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,278.83,
TROCAR SLEEVE 10-12MM ETHICON,100739,CDM,270,RC,,,,,Outpatient,,,193.7,,,,80,,154.96,percent of total billed charges,,,,85,164.65,percent of total billed charges,,,77.7,,150.5,percent of total billed charges,,,95,,184.02,percent of total billed charges,,,60,,116.22,percent of total billed charges,,116.22,184.02,
TROCAR SLEEVE 10-12MM ETHICON,100739,CDM,270,RC,,,,,Inpatient,,,193.7,,,,80,,154.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,150.5,percent of total billed charges,,,95,,184.02,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,184.02,
BLUNT DISECTORS ETHICON,100740,CDM,270,RC,,,,,Outpatient,,,68.8,,,,80,,55.04,percent of total billed charges,,,,85,58.48,percent of total billed charges,,,77.7,,53.46,percent of total billed charges,,,95,,65.36,percent of total billed charges,,,60,,41.28,percent of total billed charges,,41.28,65.36,
BLUNT DISECTORS ETHICON,100740,CDM,270,RC,,,,,Inpatient,,,68.8,,,,80,,55.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,53.46,percent of total billed charges,,,95,,65.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,65.36,
ENDOTRACH TUBE 4.0 RAE,100742,CDM,270,RC,,,,,Outpatient,,,17.4,,,,80,,13.92,percent of total billed charges,,,,85,14.79,percent of total billed charges,,,77.7,,13.52,percent of total billed charges,,,95,,16.53,percent of total billed charges,,,60,,10.44,percent of total billed charges,,10.44,16.53,
ENDOTRACH TUBE 4.0 RAE,100742,CDM,270,RC,,,,,Inpatient,,,17.4,,,,80,,13.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,13.52,percent of total billed charges,,,95,,16.53,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,16.53,
ENDOTRACH TUBE 4.5 RAE,100743,CDM,270,RC,,,,,Outpatient,,,14.5,,,,80,,11.6,percent of total billed charges,,,,85,12.33,percent of total billed charges,,,77.7,,11.27,percent of total billed charges,,,95,,13.78,percent of total billed charges,,,60,,8.7,percent of total billed charges,,8.7,13.78,
ENDOTRACH TUBE 4.5 RAE,100743,CDM,270,RC,,,,,Inpatient,,,14.5,,,,80,,11.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.27,percent of total billed charges,,,95,,13.78,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.78,
ENDOTRACH TUBE 5.0 RAE,100744,CDM,270,RC,,,,,Outpatient,,,17,,,,80,,13.6,percent of total billed charges,,,,85,14.45,percent of total billed charges,,,77.7,,13.21,percent of total billed charges,,,95,,16.15,percent of total billed charges,,,60,,10.2,percent of total billed charges,,10.2,16.15,
ENDOTRACH TUBE 5.0 RAE,100744,CDM,270,RC,,,,,Inpatient,,,17,,,,80,,13.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,13.21,percent of total billed charges,,,95,,16.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,16.15,
ENDOTRACH TUBE 5.5 RAE,100745,CDM,270,RC,,,,,Outpatient,,,14.5,,,,80,,11.6,percent of total billed charges,,,,85,12.33,percent of total billed charges,,,77.7,,11.27,percent of total billed charges,,,95,,13.78,percent of total billed charges,,,60,,8.7,percent of total billed charges,,8.7,13.78,
ENDOTRACH TUBE 5.5 RAE,100745,CDM,270,RC,,,,,Inpatient,,,14.5,,,,80,,11.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.27,percent of total billed charges,,,95,,13.78,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.78,
ENDOTRACH TUBE 6.0 RAE,100746,CDM,270,RC,,,,,Outpatient,,,15.4,,,,80,,12.32,percent of total billed charges,,,,85,13.09,percent of total billed charges,,,77.7,,11.97,percent of total billed charges,,,95,,14.63,percent of total billed charges,,,60,,9.24,percent of total billed charges,,9.24,14.63,
ENDOTRACH TUBE 6.0 RAE,100746,CDM,270,RC,,,,,Inpatient,,,15.4,,,,80,,12.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.97,percent of total billed charges,,,95,,14.63,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,14.63,
ENDOTRACH TUBE 6.5 RAE,100747,CDM,270,RC,,,,,Outpatient,,,14.5,,,,80,,11.6,percent of total billed charges,,,,85,12.33,percent of total billed charges,,,77.7,,11.27,percent of total billed charges,,,95,,13.78,percent of total billed charges,,,60,,8.7,percent of total billed charges,,8.7,13.78,
ENDOTRACH TUBE 6.5 RAE,100747,CDM,270,RC,,,,,Inpatient,,,14.5,,,,80,,11.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.27,percent of total billed charges,,,95,,13.78,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.78,
ENDOTRACH TUBE 7.0 RAE,100748,CDM,270,RC,,,,,Outpatient,,,14.5,,,,80,,11.6,percent of total billed charges,,,,85,12.33,percent of total billed charges,,,77.7,,11.27,percent of total billed charges,,,95,,13.78,percent of total billed charges,,,60,,8.7,percent of total billed charges,,8.7,13.78,
ENDOTRACH TUBE 7.0 RAE,100748,CDM,270,RC,,,,,Inpatient,,,14.5,,,,80,,11.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.27,percent of total billed charges,,,95,,13.78,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.78,
ENDOTRACH TUBE 7.5 RAE,100749,CDM,270,RC,,,,,Outpatient,,,14.5,,,,80,,11.6,percent of total billed charges,,,,85,12.33,percent of total billed charges,,,77.7,,11.27,percent of total billed charges,,,95,,13.78,percent of total billed charges,,,60,,8.7,percent of total billed charges,,8.7,13.78,
ENDOTRACH TUBE 7.5 RAE,100749,CDM,270,RC,,,,,Inpatient,,,14.5,,,,80,,11.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.27,percent of total billed charges,,,95,,13.78,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.78,
LINEAR CUTTER CTS FLEX 45 ETH,100750,CDM,270,RC,,,,,Outpatient,,,766.2,,,,80,,612.96,percent of total billed charges,,,,85,651.27,percent of total billed charges,,,77.7,,595.34,percent of total billed charges,,,95,,727.89,percent of total billed charges,,,60,,459.72,percent of total billed charges,,459.72,727.89,
LINEAR CUTTER CTS FLEX 45 ETH,100750,CDM,270,RC,,,,,Inpatient,,,766.2,,,,80,,612.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,595.34,percent of total billed charges,,,95,,727.89,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,727.89,
LINEAR STAPLER RELOAD ETS FLEX 45 BLUE,100751,CDM,270,RC,,,,,Outpatient,,,428.6,,,,80,,342.88,percent of total billed charges,,,,85,364.31,percent of total billed charges,,,77.7,,333.02,percent of total billed charges,,,95,,407.17,percent of total billed charges,,,60,,257.16,percent of total billed charges,,257.16,407.17,
LINEAR STAPLER RELOAD ETS FLEX 45 BLUE,100751,CDM,270,RC,,,,,Inpatient,,,428.6,,,,80,,342.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,333.02,percent of total billed charges,,,95,,407.17,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,407.17,
"PACKING GAUZE 1/4"" PLAIN",100752,CDM,270,RC,,,,,Outpatient,,,5.6,,,,80,,4.48,percent of total billed charges,,,,85,4.76,percent of total billed charges,,,77.7,,4.35,percent of total billed charges,,,95,,5.32,percent of total billed charges,,,60,,3.36,percent of total billed charges,,3.36,5.32,
"PACKING GAUZE 1/4"" PLAIN",100752,CDM,270,RC,,,,,Inpatient,,,5.6,,,,80,,4.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.35,percent of total billed charges,,,95,,5.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.32,
"ESMARK BANDAGE 4""X 12'",100753,CDM,270,RC,,,,,Outpatient,,,79.8,,,,80,,63.84,percent of total billed charges,,,,85,67.83,percent of total billed charges,,,77.7,,62,percent of total billed charges,,,95,,75.81,percent of total billed charges,,,60,,47.88,percent of total billed charges,,47.88,75.81,
"ESMARK BANDAGE 4""X 12'",100753,CDM,270,RC,,,,,Inpatient,,,79.8,,,,80,,63.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,62,percent of total billed charges,,,95,,75.81,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,75.81,
KNEE BRACE ROM,100754,CDM,274,RC,L1831,HCPCS,,,Outpatient,,,278.3,,,,80,,222.64,percent of total billed charges,,,,50,139.85,fee schedule,,,77.7,,216.24,percent of total billed charges,,,95,,264.39,percent of total billed charges,,,60,,166.98,percent of total billed charges,,139.85,264.39,
KNEE BRACE ROM,100754,CDM,274,RC,L1831,HCPCS,,,Inpatient,,,278.3,,,,80,,222.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,216.24,percent of total billed charges,,,95,,264.39,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,264.39,
SHOULDER IMMOBILIZER DELUXE,100757,CDM,274,RC,L3670,HCPCS,,,Outpatient,,,28.2,,,,80,,22.56,percent of total billed charges,,,,85,23.97,percent of total billed charges,,,77.7,,21.91,percent of total billed charges,,,95,,26.79,percent of total billed charges,,,60,,16.92,percent of total billed charges,,16.92,26.79,
SHOULDER IMMOBILIZER DELUXE,100757,CDM,274,RC,L3670,HCPCS,,,Inpatient,,,28.2,,,,80,,22.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,21.91,percent of total billed charges,,,95,,26.79,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,26.79,
"PACKING GAUZE 1"" PLAIN",100760,CDM,270,RC,,,,,Outpatient,,,6.6,,,,80,,5.28,percent of total billed charges,,,,85,5.61,percent of total billed charges,,,77.7,,5.13,percent of total billed charges,,,95,,6.27,percent of total billed charges,,,60,,3.96,percent of total billed charges,,3.96,6.27,
"PACKING GAUZE 1"" PLAIN",100760,CDM,270,RC,,,,,Inpatient,,,6.6,,,,80,,5.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.13,percent of total billed charges,,,95,,6.27,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.27,
"PACKING GAUZE 2"" IODOFORM",100761,CDM,270,RC,,,,,Outpatient,,,15.8,,,,80,,12.64,percent of total billed charges,,,,85,13.43,percent of total billed charges,,,77.7,,12.28,percent of total billed charges,,,95,,15.01,percent of total billed charges,,,60,,9.48,percent of total billed charges,,9.48,15.01,
"PACKING GAUZE 2"" IODOFORM",100761,CDM,270,RC,,,,,Inpatient,,,15.8,,,,80,,12.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.28,percent of total billed charges,,,95,,15.01,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.01,
TROCAR 12MM DIAL ENDOPATH ETHICON,100765,CDM,270,RC,,,,,Outpatient,,,214,,,,80,,171.2,percent of total billed charges,,,,85,181.9,percent of total billed charges,,,77.7,,166.28,percent of total billed charges,,,95,,203.3,percent of total billed charges,,,60,,128.4,percent of total billed charges,,128.4,203.3,
TROCAR 12MM DIAL ENDOPATH ETHICON,100765,CDM,270,RC,,,,,Inpatient,,,214,,,,80,,171.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,166.28,percent of total billed charges,,,95,,203.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,203.3,
ENDOSTITCH AUTOSUTURE POLYSORB 2-0,100766,CDM,270,RC,,,,,Outpatient,,,163.7,,,,80,,130.96,percent of total billed charges,,,,85,139.15,percent of total billed charges,,,77.7,,127.19,percent of total billed charges,,,95,,155.52,percent of total billed charges,,,60,,98.22,percent of total billed charges,,98.22,155.52,
ENDOSTITCH AUTOSUTURE POLYSORB 2-0,100766,CDM,270,RC,,,,,Inpatient,,,163.7,,,,80,,130.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,127.19,percent of total billed charges,,,95,,155.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,155.52,
KNEE CAGE SWEDISH,100768,CDM,274,RC,L1836,HCPCS,,,Outpatient,,,365.5,,,,80,,292.4,percent of total billed charges,,,,85,310.68,percent of total billed charges,,,77.7,,283.99,percent of total billed charges,,,95,,347.23,percent of total billed charges,,,60,,219.3,percent of total billed charges,,219.3,347.23,
KNEE CAGE SWEDISH,100768,CDM,274,RC,L1836,HCPCS,,,Inpatient,,,365.5,,,,80,,292.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,283.99,percent of total billed charges,,,95,,347.23,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,347.23,
SPIKE TUBING DAVOL,100769,CDM,270,RC,,,,,Outpatient,,,108.5,,,,80,,86.8,percent of total billed charges,,,,85,92.23,percent of total billed charges,,,77.7,,84.3,percent of total billed charges,,,95,,103.08,percent of total billed charges,,,60,,65.1,percent of total billed charges,,65.1,103.08,
SPIKE TUBING DAVOL,100769,CDM,270,RC,,,,,Inpatient,,,108.5,,,,80,,86.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,84.3,percent of total billed charges,,,95,,103.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,103.08,
THORACIC CATHETER 40 FR,100770,CDM,270,RC,,,,,Outpatient,,,16.5,,,,80,,13.2,percent of total billed charges,,,,85,14.03,percent of total billed charges,,,77.7,,12.82,percent of total billed charges,,,95,,15.68,percent of total billed charges,,,60,,9.9,percent of total billed charges,,9.9,15.68,
THORACIC CATHETER 40 FR,100770,CDM,270,RC,,,,,Inpatient,,,16.5,,,,80,,13.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.82,percent of total billed charges,,,95,,15.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.68,
THORACIC CATHETER 36 FR,100771,CDM,270,RC,,,,,Outpatient,,,13.4,,,,80,,10.72,percent of total billed charges,,,,85,11.39,percent of total billed charges,,,77.7,,10.41,percent of total billed charges,,,95,,12.73,percent of total billed charges,,,60,,8.04,percent of total billed charges,,8.04,12.73,
THORACIC CATHETER 36 FR,100771,CDM,270,RC,,,,,Inpatient,,,13.4,,,,80,,10.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.41,percent of total billed charges,,,95,,12.73,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,12.73,
MULTIFIRE GIA 60-3.8 RELOAD,100772,CDM,270,RC,,,,,Outpatient,,,3.8,,,,80,,3.04,percent of total billed charges,,,,85,3.23,percent of total billed charges,,,77.7,,2.95,percent of total billed charges,,,95,,3.61,percent of total billed charges,,,60,,2.28,percent of total billed charges,,2.28,3.61,
MULTIFIRE GIA 60-3.8 RELOAD,100772,CDM,270,RC,,,,,Inpatient,,,3.8,,,,80,,3.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.95,percent of total billed charges,,,95,,3.61,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.61,
JACKSON PRATT RESERVOIR,100775,CDM,270,RC,,,,,Outpatient,,,21.4,,,,80,,17.12,percent of total billed charges,,,,85,18.19,percent of total billed charges,,,77.7,,16.63,percent of total billed charges,,,95,,20.33,percent of total billed charges,,,60,,12.84,percent of total billed charges,,12.84,20.33,
JACKSON PRATT RESERVOIR,100775,CDM,270,RC,,,,,Inpatient,,,21.4,,,,80,,17.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,16.63,percent of total billed charges,,,95,,20.33,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,20.33,
JACKSON PRATT DRAIN,100776,CDM,270,RC,,,,,Outpatient,,,28.7,,,,80,,22.96,percent of total billed charges,,,,85,24.4,percent of total billed charges,,,77.7,,22.3,percent of total billed charges,,,95,,27.27,percent of total billed charges,,,60,,17.22,percent of total billed charges,,17.22,27.27,
JACKSON PRATT DRAIN,100776,CDM,270,RC,,,,,Inpatient,,,28.7,,,,80,,22.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,22.3,percent of total billed charges,,,95,,27.27,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,27.27,
SURGICLIP II M-9.75 AUTO SUTURE,100777,CDM,270,RC,,,,,Outpatient,,,581.6,,,,80,,465.28,percent of total billed charges,,,,85,494.36,percent of total billed charges,,,77.7,,451.9,percent of total billed charges,,,95,,552.52,percent of total billed charges,,,60,,348.96,percent of total billed charges,,348.96,552.52,
SURGICLIP II M-9.75 AUTO SUTURE,100777,CDM,270,RC,,,,,Inpatient,,,581.6,,,,80,,465.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,451.9,percent of total billed charges,,,95,,552.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,552.52,
"KERLIX FLUFF ROLL 3.4"" ST",100779,CDM,270,RC,,,,,Outpatient,,,1,,,,80,,0.8,percent of total billed charges,,,,85,0.85,percent of total billed charges,,,77.7,,0.78,percent of total billed charges,,,95,,0.95,percent of total billed charges,,,60,,0.6,percent of total billed charges,,0.6,0.95,
"KERLIX FLUFF ROLL 3.4"" ST",100779,CDM,270,RC,,,,,Inpatient,,,1,,,,80,,0.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.78,percent of total billed charges,,,95,,0.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,0.95,
"FOOT ELEVATOR 6""",100780,CDM,270,RC,,,,,Outpatient,,,70,,,,80,,56,percent of total billed charges,,,,85,59.5,percent of total billed charges,,,77.7,,54.39,percent of total billed charges,,,95,,66.5,percent of total billed charges,,,60,,42,percent of total billed charges,,42,66.5,
"FOOT ELEVATOR 6""",100780,CDM,270,RC,,,,,Inpatient,,,70,,,,80,,56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,54.39,percent of total billed charges,,,95,,66.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,66.5,
MESH MONOFIL 6X6  POLYPRO. BARD/DAVOL,100784,CDM,278,RC,C1781,HCPCS,,,Outpatient,,,388.9,,,,80,,311.12,percent of total billed charges,,,,85,330.57,percent of total billed charges,,,77.7,,302.18,percent of total billed charges,,,95,,369.46,percent of total billed charges,,,60,,233.34,percent of total billed charges,,233.34,369.46,
MESH MONOFIL 6X6  POLYPRO. BARD/DAVOL,100784,CDM,278,RC,C1781,HCPCS,,,Inpatient,,,388.9,,,,80,,311.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,302.18,percent of total billed charges,,,95,,369.46,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,369.46,
STAPLER EMS MULTIFEED-20 ETHICON,100785,CDM,270,RC,,,,,Outpatient,,,1355.2,,,,80,,1084.16,percent of total billed charges,,,,85,1151.92,percent of total billed charges,,,77.7,,1052.99,percent of total billed charges,,,95,,1287.44,percent of total billed charges,,,60,,813.12,percent of total billed charges,,813.12,1287.44,
STAPLER EMS MULTIFEED-20 ETHICON,100785,CDM,270,RC,,,,,Inpatient,,,1355.2,,,,80,,1084.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1052.99,percent of total billed charges,,,95,,1287.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1287.44,
MESH-MYCROMESH  GOR-TEX,100786,CDM,278,RC,C1781,HCPCS,,,Outpatient,,,511,,,,80,,408.8,percent of total billed charges,,,,85,434.35,percent of total billed charges,,,77.7,,397.05,percent of total billed charges,,,95,,485.45,percent of total billed charges,,,60,,306.6,percent of total billed charges,,306.6,485.45,
MESH-MYCROMESH  GOR-TEX,100786,CDM,278,RC,C1781,HCPCS,,,Inpatient,,,511,,,,80,,408.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,397.05,percent of total billed charges,,,95,,485.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,485.45,
ENDOSTITCH AUTOSUTURE,100789,CDM,270,RC,,,,,Outpatient,,,805.9,,,,80,,644.72,percent of total billed charges,,,,85,685.02,percent of total billed charges,,,77.7,,626.18,percent of total billed charges,,,95,,765.61,percent of total billed charges,,,60,,483.54,percent of total billed charges,,483.54,765.61,
ENDOSTITCH AUTOSUTURE,100789,CDM,270,RC,,,,,Inpatient,,,805.9,,,,80,,644.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,626.18,percent of total billed charges,,,95,,765.61,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,765.61,
"FOOT ELEVATOR 4"" ROUND POSEY",100790,CDM,270,RC,,,,,Outpatient,,,93.7,,,,80,,74.96,percent of total billed charges,,,,85,79.65,percent of total billed charges,,,77.7,,72.8,percent of total billed charges,,,95,,89.02,percent of total billed charges,,,60,,56.22,percent of total billed charges,,56.22,89.02,
"FOOT ELEVATOR 4"" ROUND POSEY",100790,CDM,270,RC,,,,,Inpatient,,,93.7,,,,80,,74.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,72.8,percent of total billed charges,,,95,,89.02,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,89.02,
SURGICLIP 5-9.0 AUTO SUTURE,100792,CDM,270,RC,,,,,Outpatient,,,119.5,,,,80,,95.6,percent of total billed charges,,,,85,101.58,percent of total billed charges,,,77.7,,92.85,percent of total billed charges,,,95,,113.53,percent of total billed charges,,,60,,71.7,percent of total billed charges,,71.7,113.53,
SURGICLIP 5-9.0 AUTO SUTURE,100792,CDM,270,RC,,,,,Inpatient,,,119.5,,,,80,,95.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,92.85,percent of total billed charges,,,95,,113.53,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,113.53,
UTERINE CURETTE 12MM,100793,CDM,270,RC,,,,,Outpatient,,,4.2,,,,80,,3.36,percent of total billed charges,,,,85,3.57,percent of total billed charges,,,77.7,,3.26,percent of total billed charges,,,95,,3.99,percent of total billed charges,,,60,,2.52,percent of total billed charges,,2.52,3.99,
UTERINE CURETTE 12MM,100793,CDM,270,RC,,,,,Inpatient,,,4.2,,,,80,,3.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.26,percent of total billed charges,,,95,,3.99,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.99,
ENDOSTITCH AUTOSUTURE 0-SURGIDAC,100797,CDM,270,RC,,,,,Outpatient,,,163.7,,,,80,,130.96,percent of total billed charges,,,,85,139.15,percent of total billed charges,,,77.7,,127.19,percent of total billed charges,,,95,,155.52,percent of total billed charges,,,60,,98.22,percent of total billed charges,,98.22,155.52,
ENDOSTITCH AUTOSUTURE 0-SURGIDAC,100797,CDM,270,RC,,,,,Inpatient,,,163.7,,,,80,,130.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,127.19,percent of total billed charges,,,95,,155.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,155.52,
FILTER EXTEN. SET 0.2 FILTER,100800,CDM,270,RC,,,,,Outpatient,,,15.8,,,,80,,12.64,percent of total billed charges,,,,85,13.43,percent of total billed charges,,,77.7,,12.28,percent of total billed charges,,,95,,15.01,percent of total billed charges,,,60,,9.48,percent of total billed charges,,9.48,15.01,
FILTER EXTEN. SET 0.2 FILTER,100800,CDM,270,RC,,,,,Inpatient,,,15.8,,,,80,,12.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.28,percent of total billed charges,,,95,,15.01,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.01,
FOOTDROP AND HEEL PROTECTOR,100804,CDM,270,RC,,,,,Outpatient,,,230.6,,,,80,,184.48,percent of total billed charges,,,,85,196.01,percent of total billed charges,,,77.7,,179.18,percent of total billed charges,,,95,,219.07,percent of total billed charges,,,60,,138.36,percent of total billed charges,,138.36,219.07,
FOOTDROP AND HEEL PROTECTOR,100804,CDM,270,RC,,,,,Inpatient,,,230.6,,,,80,,184.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,179.18,percent of total billed charges,,,95,,219.07,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,219.07,
PENROSE DRAIN 1/4 X 12 STERILE,100806,CDM,270,RC,,,,,Outpatient,,,6.9,,,,80,,5.52,percent of total billed charges,,,,85,5.87,percent of total billed charges,,,77.7,,5.36,percent of total billed charges,,,95,,6.56,percent of total billed charges,,,60,,4.14,percent of total billed charges,,4.14,6.56,
PENROSE DRAIN 1/4 X 12 STERILE,100806,CDM,270,RC,,,,,Inpatient,,,6.9,,,,80,,5.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.36,percent of total billed charges,,,95,,6.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.56,
CONE AND FINGER SEPERATOR,100807,CDM,270,RC,,,,,Outpatient,,,56.1,,,,80,,44.88,percent of total billed charges,,,,85,47.69,percent of total billed charges,,,77.7,,43.59,percent of total billed charges,,,95,,53.3,percent of total billed charges,,,60,,33.66,percent of total billed charges,,33.66,53.3,
CONE AND FINGER SEPERATOR,100807,CDM,270,RC,,,,,Inpatient,,,56.1,,,,80,,44.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,43.59,percent of total billed charges,,,95,,53.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,53.3,
"MEPORE DRESSING 3.6X10""",100809,CDM,270,RC,,,,,Outpatient,,,64.4,,,,80,,51.52,percent of total billed charges,,,,85,54.74,percent of total billed charges,,,77.7,,50.04,percent of total billed charges,,,95,,61.18,percent of total billed charges,,,60,,38.64,percent of total billed charges,,38.64,61.18,
"MEPORE DRESSING 3.6X10""",100809,CDM,270,RC,,,,,Inpatient,,,64.4,,,,80,,51.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,50.04,percent of total billed charges,,,95,,61.18,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,61.18,
"MESALT DRESSING 3/4 X 39""",100810,CDM,270,RC,,,,,Outpatient,,,6.4,,,,80,,5.12,percent of total billed charges,,,,85,5.44,percent of total billed charges,,,77.7,,4.97,percent of total billed charges,,,95,,6.08,percent of total billed charges,,,60,,3.84,percent of total billed charges,,3.84,6.08,
"MESALT DRESSING 3/4 X 39""",100810,CDM,270,RC,,,,,Inpatient,,,6.4,,,,80,,5.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.97,percent of total billed charges,,,95,,6.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.08,
MEPILEX 4X4 DRESSING,100812,CDM,270,RC,,,,,Outpatient,,,9.3,,,,80,,7.44,percent of total billed charges,,,,85,7.91,percent of total billed charges,,,77.7,,7.23,percent of total billed charges,,,95,,8.84,percent of total billed charges,,,60,,5.58,percent of total billed charges,,5.58,8.84,
MEPILEX 4X4 DRESSING,100812,CDM,270,RC,,,,,Inpatient,,,9.3,,,,80,,7.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.23,percent of total billed charges,,,95,,8.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,8.84,
MEPILEX 6X8 TRANSFER DRESSING,100813,CDM,270,RC,,,,,Outpatient,,,23,,,,80,,18.4,percent of total billed charges,,,,85,19.55,percent of total billed charges,,,77.7,,17.87,percent of total billed charges,,,95,,21.85,percent of total billed charges,,,60,,13.8,percent of total billed charges,,13.8,21.85,
MEPILEX 6X8 TRANSFER DRESSING,100813,CDM,270,RC,,,,,Inpatient,,,23,,,,80,,18.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,17.87,percent of total billed charges,,,95,,21.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,21.85,
HIP/KNEE KIT,100820,CDM,270,RC,,,,,Outpatient,,,94.2,,,,80,,75.36,percent of total billed charges,,,,85,80.07,percent of total billed charges,,,77.7,,73.19,percent of total billed charges,,,95,,89.49,percent of total billed charges,,,60,,56.52,percent of total billed charges,,56.52,89.49,
HIP/KNEE KIT,100820,CDM,270,RC,,,,,Inpatient,,,94.2,,,,80,,75.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,73.19,percent of total billed charges,,,95,,89.49,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,89.49,
CONTACT LENS REMOVER KIT,100823,CDM,270,RC,,,,,Outpatient,,,17.4,,,,80,,13.92,percent of total billed charges,,,,85,14.79,percent of total billed charges,,,77.7,,13.52,percent of total billed charges,,,95,,16.53,percent of total billed charges,,,60,,10.44,percent of total billed charges,,10.44,16.53,
CONTACT LENS REMOVER KIT,100823,CDM,270,RC,,,,,Inpatient,,,17.4,,,,80,,13.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,13.52,percent of total billed charges,,,95,,16.53,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,16.53,
CHLORAPREP 3 ML,100825,CDM,270,RC,,,,,Outpatient,,,3.1,,,,80,,2.48,percent of total billed charges,,,,85,2.64,percent of total billed charges,,,77.7,,2.41,percent of total billed charges,,,95,,2.95,percent of total billed charges,,,60,,1.86,percent of total billed charges,,1.86,2.95,
CHLORAPREP 3 ML,100825,CDM,270,RC,,,,,Inpatient,,,3.1,,,,80,,2.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.41,percent of total billed charges,,,95,,2.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.95,
ZZZHAND ORTHOSIS UNIV,100831,CDM,274,RC,L3807,HCPCS,,,Outpatient,,,290.5,,,,80,,232.4,percent of total billed charges,,,,85,246.93,percent of total billed charges,,,77.7,,225.72,percent of total billed charges,,,95,,275.98,percent of total billed charges,,,60,,174.3,percent of total billed charges,,174.3,275.98,
ZZZHAND ORTHOSIS UNIV,100831,CDM,274,RC,L3807,HCPCS,,,Inpatient,,,290.5,,,,80,,232.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,225.72,percent of total billed charges,,,95,,275.98,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,275.98,
REMOVER LOTION 1/2 OZ,100832,CDM,270,RC,,,,,Outpatient,,,2.2,,,,80,,1.76,percent of total billed charges,,,,85,1.87,percent of total billed charges,,,77.7,,1.71,percent of total billed charges,,,95,,2.09,percent of total billed charges,,,60,,1.32,percent of total billed charges,,1.32,2.09,
REMOVER LOTION 1/2 OZ,100832,CDM,270,RC,,,,,Inpatient,,,2.2,,,,80,,1.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.71,percent of total billed charges,,,95,,2.09,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.09,
TEGASORB 4 X 4 3/4 THIN,100833,CDM,270,RC,,,,,Outpatient,,,14,,,,80,,11.2,percent of total billed charges,,,,85,11.9,percent of total billed charges,,,77.7,,10.88,percent of total billed charges,,,95,,13.3,percent of total billed charges,,,60,,8.4,percent of total billed charges,,8.4,13.3,
TEGASORB 4 X 4 3/4 THIN,100833,CDM,270,RC,,,,,Inpatient,,,14,,,,80,,11.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.88,percent of total billed charges,,,95,,13.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.3,
ADAPTIC DRESSING 3X8,100834,CDM,270,RC,,,,,Outpatient,,,2.3,,,,80,,1.84,percent of total billed charges,,,,85,1.96,percent of total billed charges,,,77.7,,1.79,percent of total billed charges,,,95,,2.19,percent of total billed charges,,,60,,1.38,percent of total billed charges,,1.38,2.19,
ADAPTIC DRESSING 3X8,100834,CDM,270,RC,,,,,Inpatient,,,2.3,,,,80,,1.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.79,percent of total billed charges,,,95,,2.19,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.19,
SNARE OVAL 25MM OLYMPUS,100836,CDM,270,RC,,,,,Outpatient,,,42.7,,,,80,,34.16,percent of total billed charges,,,,85,36.3,percent of total billed charges,,,77.7,,33.18,percent of total billed charges,,,95,,40.57,percent of total billed charges,,,60,,25.62,percent of total billed charges,,25.62,40.57,
SNARE OVAL 25MM OLYMPUS,100836,CDM,270,RC,,,,,Inpatient,,,42.7,,,,80,,34.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,33.18,percent of total billed charges,,,95,,40.57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,40.57,
BIOPATCH DRESSING,100837,CDM,623,RC,A6209,HCPCS,,,Outpatient,,,11.8,,,,80,,9.44,percent of total billed charges,,,,85,10.03,percent of total billed charges,,,77.7,,9.17,percent of total billed charges,,,95,,11.21,percent of total billed charges,,,60,,7.08,percent of total billed charges,,7.08,11.21,
BIOPATCH DRESSING,100837,CDM,623,RC,A6209,HCPCS,,,Inpatient,,,11.8,,,,80,,9.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.17,percent of total billed charges,,,95,,11.21,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.21,
FOOT ORTHOSIS LG RT,100838,CDM,270,RC,,,,,Outpatient,,,154.7,,,,80,,123.76,percent of total billed charges,,,,85,131.5,percent of total billed charges,,,77.7,,120.2,percent of total billed charges,,,95,,146.97,percent of total billed charges,,,60,,92.82,percent of total billed charges,,92.82,146.97,
FOOT ORTHOSIS LG RT,100838,CDM,270,RC,,,,,Inpatient,,,154.7,,,,80,,123.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,120.2,percent of total billed charges,,,95,,146.97,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,146.97,
TEGADERM 4 X 4 3/4,100840,CDM,270,RC,,,,,Outpatient,,,3.3,,,,80,,2.64,percent of total billed charges,,,,85,2.81,percent of total billed charges,,,77.7,,2.56,percent of total billed charges,,,95,,3.14,percent of total billed charges,,,60,,1.98,percent of total billed charges,,1.98,3.14,
TEGADERM 4 X 4 3/4,100840,CDM,270,RC,,,,,Inpatient,,,3.3,,,,80,,2.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.56,percent of total billed charges,,,95,,3.14,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.14,
ARM BOARD INFANT/PED,100843,CDM,270,RC,,,,,Outpatient,,,1.1,,,,80,,0.88,percent of total billed charges,,,,85,0.94,percent of total billed charges,,,77.7,,0.85,percent of total billed charges,,,95,,1.05,percent of total billed charges,,,60,,0.66,percent of total billed charges,,0.66,1.05,
ARM BOARD INFANT/PED,100843,CDM,270,RC,,,,,Inpatient,,,1.1,,,,80,,0.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.85,percent of total billed charges,,,95,,1.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.05,
TROCAR 8MM BLADELESS ETHICON,100844,CDM,270,RC,,,,,Outpatient,,,211.3,,,,80,,169.04,percent of total billed charges,,,,85,179.61,percent of total billed charges,,,77.7,,164.18,percent of total billed charges,,,95,,200.74,percent of total billed charges,,,60,,126.78,percent of total billed charges,,126.78,200.74,
TROCAR 8MM BLADELESS ETHICON,100844,CDM,270,RC,,,,,Inpatient,,,211.3,,,,80,,169.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,164.18,percent of total billed charges,,,95,,200.74,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,200.74,
CAUTERY TIP GUARDED NEEDLE AARON,100845,CDM,270,RC,,,,,Outpatient,,,14.7,,,,80,,11.76,percent of total billed charges,,,,85,12.5,percent of total billed charges,,,77.7,,11.42,percent of total billed charges,,,95,,13.97,percent of total billed charges,,,60,,8.82,percent of total billed charges,,8.82,13.97,
CAUTERY TIP GUARDED NEEDLE AARON,100845,CDM,270,RC,,,,,Inpatient,,,14.7,,,,80,,11.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.42,percent of total billed charges,,,95,,13.97,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.97,
MESH 3D MAX LEFT MED DAVOL,100846,CDM,278,RC,C1781,HCPCS,,,Outpatient,,,560,,,,80,,448,percent of total billed charges,,,,85,476,percent of total billed charges,,,77.7,,435.12,percent of total billed charges,,,95,,532,percent of total billed charges,,,60,,336,percent of total billed charges,,336,532,
MESH 3D MAX LEFT MED DAVOL,100846,CDM,278,RC,C1781,HCPCS,,,Inpatient,,,560,,,,80,,448,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,435.12,percent of total billed charges,,,95,,532,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,532,
SALUTE 38CM 10 QRING DAVOL,100847,CDM,270,RC,,,,,Outpatient,,,805,,,,80,,644,percent of total billed charges,,,,85,684.25,percent of total billed charges,,,77.7,,625.49,percent of total billed charges,,,95,,764.75,percent of total billed charges,,,60,,483,percent of total billed charges,,483,764.75,
SALUTE 38CM 10 QRING DAVOL,100847,CDM,270,RC,,,,,Inpatient,,,805,,,,80,,644,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,625.49,percent of total billed charges,,,95,,764.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,764.75,
TROCAR 12MM XCEL BLADELESS ETHICON,100848,CDM,270,RC,,,,,Outpatient,,,259.9,,,,80,,207.92,percent of total billed charges,,,,85,220.92,percent of total billed charges,,,77.7,,201.94,percent of total billed charges,,,95,,246.91,percent of total billed charges,,,60,,155.94,percent of total billed charges,,155.94,246.91,
TROCAR 12MM XCEL BLADELESS ETHICON,100848,CDM,270,RC,,,,,Inpatient,,,259.9,,,,80,,207.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,201.94,percent of total billed charges,,,95,,246.91,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,246.91,
TROCAR 10MM W/BALLOON AUTOSUTURE,100851,CDM,270,RC,,,,,Outpatient,,,613.2,,,,80,,490.56,percent of total billed charges,,,,85,521.22,percent of total billed charges,,,77.7,,476.46,percent of total billed charges,,,95,,582.54,percent of total billed charges,,,60,,367.92,percent of total billed charges,,367.92,582.54,
TROCAR 10MM W/BALLOON AUTOSUTURE,100851,CDM,270,RC,,,,,Inpatient,,,613.2,,,,80,,490.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,476.46,percent of total billed charges,,,95,,582.54,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,582.54,
TROCAR 5MM SLEEVE/OPTIVIEW,100852,CDM,270,RC,,,,,Outpatient,,,80.3,,,,80,,64.24,percent of total billed charges,,,,85,68.26,percent of total billed charges,,,77.7,,62.39,percent of total billed charges,,,95,,76.29,percent of total billed charges,,,60,,48.18,percent of total billed charges,,48.18,76.29,
TROCAR 5MM SLEEVE/OPTIVIEW,100852,CDM,270,RC,,,,,Inpatient,,,80.3,,,,80,,64.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,62.39,percent of total billed charges,,,95,,76.29,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,76.29,
TROCAR 5MM W/2 CANNULAS,100853,CDM,270,RC,,,,,Outpatient,,,143.2,,,,80,,114.56,percent of total billed charges,,,,85,121.72,percent of total billed charges,,,77.7,,111.27,percent of total billed charges,,,95,,136.04,percent of total billed charges,,,60,,85.92,percent of total billed charges,,85.92,136.04,
TROCAR 5MM W/2 CANNULAS,100853,CDM,270,RC,,,,,Inpatient,,,143.2,,,,80,,114.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,111.27,percent of total billed charges,,,95,,136.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,136.04,
SALUTE 38CM 20 QRING DAVOL,100854,CDM,270,RC,,,,,Outpatient,,,1340.5,,,,80,,1072.4,percent of total billed charges,,,,85,1139.43,percent of total billed charges,,,77.7,,1041.57,percent of total billed charges,,,95,,1273.48,percent of total billed charges,,,60,,804.3,percent of total billed charges,,804.3,1273.48,
SALUTE 38CM 20 QRING DAVOL,100854,CDM,270,RC,,,,,Inpatient,,,1340.5,,,,80,,1072.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1041.57,percent of total billed charges,,,95,,1273.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1273.48,
MESH 3D MAX LEFT LARGE DAVOL,100855,CDM,278,RC,C1781,HCPCS,,,Outpatient,,,749.9,,,,80,,599.92,percent of total billed charges,,,,85,637.42,percent of total billed charges,,,77.7,,582.67,percent of total billed charges,,,95,,712.41,percent of total billed charges,,,60,,449.94,percent of total billed charges,,449.94,712.41,
MESH 3D MAX LEFT LARGE DAVOL,100855,CDM,278,RC,C1781,HCPCS,,,Inpatient,,,749.9,,,,80,,599.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,582.67,percent of total billed charges,,,95,,712.41,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,712.41,
BLOOD FLUID WARMING SET,100858,CDM,270,RC,,,,,Outpatient,,,33.9,,,,80,,27.12,percent of total billed charges,,,,85,28.82,percent of total billed charges,,,77.7,,26.34,percent of total billed charges,,,95,,32.21,percent of total billed charges,,,60,,20.34,percent of total billed charges,,20.34,32.21,
BLOOD FLUID WARMING SET,100858,CDM,270,RC,,,,,Inpatient,,,33.9,,,,80,,27.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,26.34,percent of total billed charges,,,95,,32.21,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,32.21,
ONE STEP SPLINT 4 X 30,100859,CDM,270,RC,,,,,Outpatient,,,57.1,,,,80,,45.68,percent of total billed charges,,,,85,48.54,percent of total billed charges,,,77.7,,44.37,percent of total billed charges,,,95,,54.25,percent of total billed charges,,,60,,34.26,percent of total billed charges,,34.26,54.25,
ONE STEP SPLINT 4 X 30,100859,CDM,270,RC,,,,,Inpatient,,,57.1,,,,80,,45.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,44.37,percent of total billed charges,,,95,,54.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,54.25,
HYDROFERA BLUE 4X4 DRESSING,100860,CDM,270,RC,,,,,Outpatient,,,22.9,,,,80,,18.32,percent of total billed charges,,,,85,19.47,percent of total billed charges,,,77.7,,17.79,percent of total billed charges,,,95,,21.76,percent of total billed charges,,,60,,13.74,percent of total billed charges,,13.74,21.76,
HYDROFERA BLUE 4X4 DRESSING,100860,CDM,270,RC,,,,,Inpatient,,,22.9,,,,80,,18.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,17.79,percent of total billed charges,,,95,,21.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,21.76,
ONE STEP SPLINT 4 X 15,100861,CDM,270,RC,,,,,Outpatient,,,14.6,,,,80,,11.68,percent of total billed charges,,,,85,12.41,percent of total billed charges,,,77.7,,11.34,percent of total billed charges,,,95,,13.87,percent of total billed charges,,,60,,8.76,percent of total billed charges,,8.76,13.87,
ONE STEP SPLINT 4 X 15,100861,CDM,270,RC,,,,,Inpatient,,,14.6,,,,80,,11.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.34,percent of total billed charges,,,95,,13.87,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.87,
OPTICHAMBER,100873,CDM,270,RC,,,,,Outpatient,,,20.3,,,,80,,16.24,percent of total billed charges,,,,85,17.26,percent of total billed charges,,,77.7,,15.77,percent of total billed charges,,,95,,19.29,percent of total billed charges,,,60,,12.18,percent of total billed charges,,12.18,19.29,
OPTICHAMBER,100873,CDM,270,RC,,,,,Inpatient,,,20.3,,,,80,,16.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,15.77,percent of total billed charges,,,95,,19.29,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,19.29,
ACAPELLA ADULT(FLUTTER),100874,CDM,270,RC,,,,,Outpatient,,,267.4,,,,80,,213.92,percent of total billed charges,,,,85,227.29,percent of total billed charges,,,77.7,,207.77,percent of total billed charges,,,95,,254.03,percent of total billed charges,,,60,,160.44,percent of total billed charges,,160.44,254.03,
ACAPELLA ADULT(FLUTTER),100874,CDM,270,RC,,,,,Inpatient,,,267.4,,,,80,,213.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,207.77,percent of total billed charges,,,95,,254.03,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,254.03,
EZ PAP,100875,CDM,270,RC,,,,,Outpatient,,,73.7,,,,80,,58.96,percent of total billed charges,,,,85,62.65,percent of total billed charges,,,77.7,,57.26,percent of total billed charges,,,95,,70.02,percent of total billed charges,,,60,,44.22,percent of total billed charges,,44.22,70.02,
EZ PAP,100875,CDM,270,RC,,,,,Inpatient,,,73.7,,,,80,,58.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,57.26,percent of total billed charges,,,95,,70.02,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,70.02,
ZZZHAND ORTHOSIS MED RIGHT,100876,CDM,274,RC,L3807,HCPCS,,,Outpatient,,,235.1,,,,80,,188.08,percent of total billed charges,,,,85,199.84,percent of total billed charges,,,77.7,,182.67,percent of total billed charges,,,95,,223.35,percent of total billed charges,,,60,,141.06,percent of total billed charges,,141.06,223.35,
ZZZHAND ORTHOSIS MED RIGHT,100876,CDM,274,RC,L3807,HCPCS,,,Inpatient,,,235.1,,,,80,,188.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,182.67,percent of total billed charges,,,95,,223.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,223.35,
ENDOCLOSE AUTO SUTURE,100879,CDM,270,RC,,,,,Outpatient,,,235.6,,,,80,,188.48,percent of total billed charges,,,,85,200.26,percent of total billed charges,,,77.7,,183.06,percent of total billed charges,,,95,,223.82,percent of total billed charges,,,60,,141.36,percent of total billed charges,,141.36,223.82,
ENDOCLOSE AUTO SUTURE,100879,CDM,270,RC,,,,,Inpatient,,,235.6,,,,80,,188.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,183.06,percent of total billed charges,,,95,,223.82,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,223.82,
MESH PROCEED 6X8,100880,CDM,278,RC,C1781,HCPCS,,,Outpatient,,,302.6,,,,80,,242.08,percent of total billed charges,,,,85,257.21,percent of total billed charges,,,77.7,,235.12,percent of total billed charges,,,95,,287.47,percent of total billed charges,,,60,,181.56,percent of total billed charges,,181.56,287.47,
MESH PROCEED 6X8,100880,CDM,278,RC,C1781,HCPCS,,,Inpatient,,,302.6,,,,80,,242.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,235.12,percent of total billed charges,,,95,,287.47,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,287.47,
TROCAR 11MM XCEL BLADELESS ETHICON,100882,CDM,270,RC,,,,,Outpatient,,,81.1,,,,80,,64.88,percent of total billed charges,,,,85,68.94,percent of total billed charges,,,77.7,,63.01,percent of total billed charges,,,95,,77.05,percent of total billed charges,,,60,,48.66,percent of total billed charges,,48.66,77.05,
TROCAR 11MM XCEL BLADELESS ETHICON,100882,CDM,270,RC,,,,,Inpatient,,,81.1,,,,80,,64.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,63.01,percent of total billed charges,,,95,,77.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.05,
LINEAR CUTTER RELOAD  2.5MM ETH,100883,CDM,270,RC,,,,,Outpatient,,,478.7,,,,80,,382.96,percent of total billed charges,,,,85,406.9,percent of total billed charges,,,77.7,,371.95,percent of total billed charges,,,95,,454.77,percent of total billed charges,,,60,,287.22,percent of total billed charges,,287.22,454.77,
LINEAR CUTTER RELOAD  2.5MM ETH,100883,CDM,270,RC,,,,,Inpatient,,,478.7,,,,80,,382.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,371.95,percent of total billed charges,,,95,,454.77,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,454.77,
MINERVA ABLATION,100884,CDM,270,RC,,,,,Outpatient,,,5250,,,,80,,4200,percent of total billed charges,,,,85,4462.5,percent of total billed charges,,,77.7,,4079.25,percent of total billed charges,,,95,,4987.5,percent of total billed charges,,,60,,3150,percent of total billed charges,,3150,4987.5,
MINERVA ABLATION,100884,CDM,270,RC,,,,,Inpatient,,,5250,,,,80,,4200,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4079.25,percent of total billed charges,,,95,,4987.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4987.5,
NEOPUFF RESUSCITATION T-PIECE KIT,100885,CDM,270,RC,,,,,Outpatient,,,40.8,,,,80,,32.64,percent of total billed charges,,,,85,34.68,percent of total billed charges,,,77.7,,31.7,percent of total billed charges,,,95,,38.76,percent of total billed charges,,,60,,24.48,percent of total billed charges,,24.48,38.76,
NEOPUFF RESUSCITATION T-PIECE KIT,100885,CDM,270,RC,,,,,Inpatient,,,40.8,,,,80,,32.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,31.7,percent of total billed charges,,,95,,38.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,38.76,
NEOPUFF MASK SIZE 2,100886,CDM,270,RC,,,,,Outpatient,,,21.4,,,,80,,17.12,percent of total billed charges,,,,85,18.19,percent of total billed charges,,,77.7,,16.63,percent of total billed charges,,,95,,20.33,percent of total billed charges,,,60,,12.84,percent of total billed charges,,12.84,20.33,
NEOPUFF MASK SIZE 2,100886,CDM,270,RC,,,,,Inpatient,,,21.4,,,,80,,17.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,16.63,percent of total billed charges,,,95,,20.33,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,20.33,
NEOPUFF MASK SIZE 3,100887,CDM,270,RC,,,,,Outpatient,,,23.7,,,,80,,18.96,percent of total billed charges,,,,85,20.15,percent of total billed charges,,,77.7,,18.41,percent of total billed charges,,,95,,22.52,percent of total billed charges,,,60,,14.22,percent of total billed charges,,14.22,22.52,
NEOPUFF MASK SIZE 3,100887,CDM,270,RC,,,,,Inpatient,,,23.7,,,,80,,18.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,18.41,percent of total billed charges,,,95,,22.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,22.52,
OSTOMY POUCH CLAMP,100891,CDM,270,RC,,,,,Outpatient,,,2.7,,,,80,,2.16,percent of total billed charges,,,,85,2.3,percent of total billed charges,,,77.7,,2.1,percent of total billed charges,,,95,,2.57,percent of total billed charges,,,60,,1.62,percent of total billed charges,,1.62,2.57,
OSTOMY POUCH CLAMP,100891,CDM,270,RC,,,,,Inpatient,,,2.7,,,,80,,2.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.1,percent of total billed charges,,,95,,2.57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.57,
BAKER JEJUNOSTOMY CATHETER 16FR,100892,CDM,270,RC,,,,,Outpatient,,,362.1,,,,80,,289.68,percent of total billed charges,,,,85,307.79,percent of total billed charges,,,77.7,,281.35,percent of total billed charges,,,95,,344,percent of total billed charges,,,60,,217.26,percent of total billed charges,,217.26,344,
BAKER JEJUNOSTOMY CATHETER 16FR,100892,CDM,270,RC,,,,,Inpatient,,,362.1,,,,80,,289.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,281.35,percent of total billed charges,,,95,,344,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,344,
RATESAVER FEEDING BAG,100893,CDM,270,RC,,,,,Outpatient,,,55.2,,,,80,,44.16,percent of total billed charges,,,,85,46.92,percent of total billed charges,,,77.7,,42.89,percent of total billed charges,,,95,,52.44,percent of total billed charges,,,60,,33.12,percent of total billed charges,,33.12,52.44,
RATESAVER FEEDING BAG,100893,CDM,270,RC,,,,,Inpatient,,,55.2,,,,80,,44.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,42.89,percent of total billed charges,,,95,,52.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,52.44,
KANGAROO SPIKE PUMP SET,100894,CDM,270,RC,,,,,Outpatient,,,6.8,,,,80,,5.44,percent of total billed charges,,,,85,5.78,percent of total billed charges,,,77.7,,5.28,percent of total billed charges,,,95,,6.46,percent of total billed charges,,,60,,4.08,percent of total billed charges,,4.08,6.46,
KANGAROO SPIKE PUMP SET,100894,CDM,270,RC,,,,,Inpatient,,,6.8,,,,80,,5.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.28,percent of total billed charges,,,95,,6.46,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.46,
SKIN BARRIER PREP COLOPLAST,100895,CDM,270,RC,,,,,Outpatient,,,0.6,,,,80,,0.48,percent of total billed charges,,,,85,0.51,percent of total billed charges,,,77.7,,0.47,percent of total billed charges,,,95,,0.57,percent of total billed charges,,,60,,0.36,percent of total billed charges,,0.36,0.57,
SKIN BARRIER PREP COLOPLAST,100895,CDM,270,RC,,,,,Inpatient,,,0.6,,,,80,,0.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.47,percent of total billed charges,,,95,,0.57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,0.57,
FEEDING TUBE MIC GASTROSTOMY 12 FR,100896,CDM,270,RC,,,,,Outpatient,,,156.5,,,,80,,125.2,percent of total billed charges,,,,85,133.03,percent of total billed charges,,,77.7,,121.6,percent of total billed charges,,,95,,148.68,percent of total billed charges,,,60,,93.9,percent of total billed charges,,93.9,148.68,
FEEDING TUBE MIC GASTROSTOMY 12 FR,100896,CDM,270,RC,,,,,Inpatient,,,156.5,,,,80,,125.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,121.6,percent of total billed charges,,,95,,148.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,148.68,
SALUTE SET 10 SHOT DISP,100897,CDM,270,RC,,,,,Outpatient,,,885.5,,,,80,,708.4,percent of total billed charges,,,,85,752.68,percent of total billed charges,,,77.7,,688.03,percent of total billed charges,,,95,,841.23,percent of total billed charges,,,60,,531.3,percent of total billed charges,,531.3,841.23,
SALUTE SET 10 SHOT DISP,100897,CDM,270,RC,,,,,Inpatient,,,885.5,,,,80,,708.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,688.03,percent of total billed charges,,,95,,841.23,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,841.23,
VAC GRANU FOAM DRESSING LG BLACK,100898,CDM,270,RC,,,,,Outpatient,,,203.3,,,,80,,162.64,percent of total billed charges,,,,85,172.81,percent of total billed charges,,,77.7,,157.96,percent of total billed charges,,,95,,193.14,percent of total billed charges,,,60,,121.98,percent of total billed charges,,121.98,193.14,
VAC GRANU FOAM DRESSING LG BLACK,100898,CDM,270,RC,,,,,Inpatient,,,203.3,,,,80,,162.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,157.96,percent of total billed charges,,,95,,193.14,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,193.14,
VAC CANISTER W/GEL,100899,CDM,270,RC,,,,,Outpatient,,,127.4,,,,80,,101.92,percent of total billed charges,,,,85,108.29,percent of total billed charges,,,77.7,,98.99,percent of total billed charges,,,95,,121.03,percent of total billed charges,,,60,,76.44,percent of total billed charges,,76.44,121.03,
VAC CANISTER W/GEL,100899,CDM,270,RC,,,,,Inpatient,,,127.4,,,,80,,101.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,98.99,percent of total billed charges,,,95,,121.03,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,121.03,
PRISMA DRESSING 4.34 X 4.34 J&J,100900,CDM,623,RC,A6219,HCPCS,,,Outpatient,,,32.8,,,,80,,26.24,percent of total billed charges,,,,85,27.88,percent of total billed charges,,,77.7,,25.49,percent of total billed charges,,,95,,31.16,percent of total billed charges,,,60,,19.68,percent of total billed charges,,19.68,31.16,
PRISMA DRESSING 4.34 X 4.34 J&J,100900,CDM,623,RC,A6219,HCPCS,,,Inpatient,,,32.8,,,,80,,26.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,25.49,percent of total billed charges,,,95,,31.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,31.16,
INFU SURGE PRESSURE BAG 1000ml,100902,CDM,270,RC,,,,,Outpatient,,,30.6,,,,80,,24.48,percent of total billed charges,,,,85,26.01,percent of total billed charges,,,77.7,,23.78,percent of total billed charges,,,95,,29.07,percent of total billed charges,,,60,,18.36,percent of total billed charges,,18.36,29.07,
INFU SURGE PRESSURE BAG 1000ml,100902,CDM,270,RC,,,,,Inpatient,,,30.6,,,,80,,24.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,23.78,percent of total billed charges,,,95,,29.07,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,29.07,
VAC GRANU FOAM DRESSING MED BLACK,100903,CDM,270,RC,,,,,Outpatient,,,154.1,,,,80,,123.28,percent of total billed charges,,,,85,130.99,percent of total billed charges,,,77.7,,119.74,percent of total billed charges,,,95,,146.4,percent of total billed charges,,,60,,92.46,percent of total billed charges,,92.46,146.4,
VAC GRANU FOAM DRESSING MED BLACK,100903,CDM,270,RC,,,,,Inpatient,,,154.1,,,,80,,123.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,119.74,percent of total billed charges,,,95,,146.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,146.4,
VAC WHITE FOAM DRESSING LARGE,100904,CDM,270,RC,,,,,Outpatient,,,46.6,,,,80,,37.28,percent of total billed charges,,,,85,39.61,percent of total billed charges,,,77.7,,36.21,percent of total billed charges,,,95,,44.27,percent of total billed charges,,,60,,27.96,percent of total billed charges,,27.96,44.27,
VAC WHITE FOAM DRESSING LARGE,100904,CDM,270,RC,,,,,Inpatient,,,46.6,,,,80,,37.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,36.21,percent of total billed charges,,,95,,44.27,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,44.27,
ESSURE SYSTEM,100905,CDM,278,RC,A4264,HCPCS,,,Outpatient,,,3237.5,,,,80,,2590,percent of total billed charges,,,,85,2751.88,percent of total billed charges,,,77.7,,2515.54,percent of total billed charges,,,95,,3075.63,percent of total billed charges,,,60,,1942.5,percent of total billed charges,,1942.5,3075.63,
ESSURE SYSTEM,100905,CDM,278,RC,A4264,HCPCS,,,Inpatient,,,3237.5,,,,80,,2590,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2515.54,percent of total billed charges,,,95,,3075.63,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3075.63,
CYSTO/BLADDER IRRIG SET,100906,CDM,270,RC,,,,,Outpatient,,,0.4,,,,80,,0.32,percent of total billed charges,,,,85,0.34,percent of total billed charges,,,77.7,,0.31,percent of total billed charges,,,95,,0.38,percent of total billed charges,,,60,,0.24,percent of total billed charges,,0.24,0.38,
CYSTO/BLADDER IRRIG SET,100906,CDM,270,RC,,,,,Inpatient,,,0.4,,,,80,,0.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.31,percent of total billed charges,,,95,,0.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,0.38,
VAC SEAL,100907,CDM,270,RC,,,,,Outpatient,,,22.4,,,,80,,17.92,percent of total billed charges,,,,85,19.04,percent of total billed charges,,,77.7,,17.4,percent of total billed charges,,,95,,21.28,percent of total billed charges,,,60,,13.44,percent of total billed charges,,13.44,21.28,
VAC SEAL,100907,CDM,270,RC,,,,,Inpatient,,,22.4,,,,80,,17.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,17.4,percent of total billed charges,,,95,,21.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,21.28,
NASAL AIRWAY 20FR LF PVC,100909,CDM,270,RC,,,,,Outpatient,,,6.4,,,,80,,5.12,percent of total billed charges,,,,85,5.44,percent of total billed charges,,,77.7,,4.97,percent of total billed charges,,,95,,6.08,percent of total billed charges,,,60,,3.84,percent of total billed charges,,3.84,6.08,
NASAL AIRWAY 20FR LF PVC,100909,CDM,270,RC,,,,,Inpatient,,,6.4,,,,80,,5.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.97,percent of total billed charges,,,95,,6.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.08,
NASAL AIRWAY 22FR LF PVC,100910,CDM,270,RC,,,,,Outpatient,,,6.3,,,,80,,5.04,percent of total billed charges,,,,85,5.36,percent of total billed charges,,,77.7,,4.9,percent of total billed charges,,,95,,5.99,percent of total billed charges,,,60,,3.78,percent of total billed charges,,3.78,5.99,
NASAL AIRWAY 22FR LF PVC,100910,CDM,270,RC,,,,,Inpatient,,,6.3,,,,80,,5.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.9,percent of total billed charges,,,95,,5.99,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.99,
NASAL AIRWAY 24FR LF PVC,100911,CDM,270,RC,,,,,Outpatient,,,6.3,,,,80,,5.04,percent of total billed charges,,,,85,5.36,percent of total billed charges,,,77.7,,4.9,percent of total billed charges,,,95,,5.99,percent of total billed charges,,,60,,3.78,percent of total billed charges,,3.78,5.99,
NASAL AIRWAY 24FR LF PVC,100911,CDM,270,RC,,,,,Inpatient,,,6.3,,,,80,,5.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.9,percent of total billed charges,,,95,,5.99,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.99,
TURBINATE WAND REFLEX ULTRA PED,100913,CDM,270,RC,,,,,Outpatient,,,937.2,,,,80,,749.76,percent of total billed charges,,,,85,796.62,percent of total billed charges,,,77.7,,728.2,percent of total billed charges,,,95,,890.34,percent of total billed charges,,,60,,562.32,percent of total billed charges,,562.32,890.34,
TURBINATE WAND REFLEX ULTRA PED,100913,CDM,270,RC,,,,,Inpatient,,,937.2,,,,80,,749.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,728.2,percent of total billed charges,,,95,,890.34,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,890.34,
ENDOTRACH TUBE 3.0 CUFFED,100914,CDM,270,RC,,,,,Outpatient,,,5.9,,,,80,,4.72,percent of total billed charges,,,,85,5.02,percent of total billed charges,,,77.7,,4.58,percent of total billed charges,,,95,,5.61,percent of total billed charges,,,60,,3.54,percent of total billed charges,,3.54,5.61,
ENDOTRACH TUBE 3.0 CUFFED,100914,CDM,270,RC,,,,,Inpatient,,,5.9,,,,80,,4.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.58,percent of total billed charges,,,95,,5.61,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.61,
BIPAP CIRCUIT,100915,CDM,270,RC,,,,,Outpatient,,,22.8,,,,80,,18.24,percent of total billed charges,,,,85,19.38,percent of total billed charges,,,77.7,,17.72,percent of total billed charges,,,95,,21.66,percent of total billed charges,,,60,,13.68,percent of total billed charges,,13.68,21.66,
BIPAP CIRCUIT,100915,CDM,270,RC,,,,,Inpatient,,,22.8,,,,80,,18.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,17.72,percent of total billed charges,,,95,,21.66,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,21.66,
OSTOMY ADAPT BARRIER STRIPS,100916,CDM,270,RC,,,,,Outpatient,,,9.7,,,,80,,7.76,percent of total billed charges,,,,85,8.25,percent of total billed charges,,,77.7,,7.54,percent of total billed charges,,,95,,9.22,percent of total billed charges,,,60,,5.82,percent of total billed charges,,5.82,9.22,
OSTOMY ADAPT BARRIER STRIPS,100916,CDM,270,RC,,,,,Inpatient,,,9.7,,,,80,,7.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.54,percent of total billed charges,,,95,,9.22,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.22,
OSTOMY CONVEX CENTER POINT LOCK,100917,CDM,270,RC,,,,,Outpatient,,,4.8,,,,80,,3.84,percent of total billed charges,,,,85,4.08,percent of total billed charges,,,77.7,,3.73,percent of total billed charges,,,95,,4.56,percent of total billed charges,,,60,,2.88,percent of total billed charges,,2.88,4.56,
OSTOMY CONVEX CENTER POINT LOCK,100917,CDM,270,RC,,,,,Inpatient,,,4.8,,,,80,,3.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.73,percent of total billed charges,,,95,,4.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.56,
OSTOMY PREMIUM POWDER,100918,CDM,270,RC,,,,,Outpatient,,,9.9,,,,80,,7.92,percent of total billed charges,,,,85,8.42,percent of total billed charges,,,77.7,,7.69,percent of total billed charges,,,95,,9.41,percent of total billed charges,,,60,,5.94,percent of total billed charges,,5.94,9.41,
OSTOMY PREMIUM POWDER,100918,CDM,270,RC,,,,,Inpatient,,,9.9,,,,80,,7.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.69,percent of total billed charges,,,95,,9.41,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.41,
"VASELINE GAUZE PACKING STRIP 1/2""",100922,CDM,270,RC,,,,,Outpatient,,,3.6,,,,80,,2.88,percent of total billed charges,,,,85,3.06,percent of total billed charges,,,77.7,,2.8,percent of total billed charges,,,95,,3.42,percent of total billed charges,,,60,,2.16,percent of total billed charges,,2.16,3.42,
"VASELINE GAUZE PACKING STRIP 1/2""",100922,CDM,270,RC,,,,,Inpatient,,,3.6,,,,80,,2.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.8,percent of total billed charges,,,95,,3.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.42,
NASAL DRESSING HOLDER,100924,CDM,270,RC,,,,,Outpatient,,,16.5,,,,80,,13.2,percent of total billed charges,,,,85,14.03,percent of total billed charges,,,77.7,,12.82,percent of total billed charges,,,95,,15.68,percent of total billed charges,,,60,,9.9,percent of total billed charges,,9.9,15.68,
NASAL DRESSING HOLDER,100924,CDM,270,RC,,,,,Inpatient,,,16.5,,,,80,,13.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.82,percent of total billed charges,,,95,,15.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.68,
AMBU BAG DISP PED,100925,CDM,270,RC,,,,,Outpatient,,,35.6,,,,80,,28.48,percent of total billed charges,,,,85,30.26,percent of total billed charges,,,77.7,,27.66,percent of total billed charges,,,95,,33.82,percent of total billed charges,,,60,,21.36,percent of total billed charges,,21.36,33.82,
AMBU BAG DISP PED,100925,CDM,270,RC,,,,,Inpatient,,,35.6,,,,80,,28.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,27.66,percent of total billed charges,,,95,,33.82,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,33.82,
MYRINGOTOMY BLADE ARROW,100930,CDM,270,RC,,,,,Outpatient,,,24.6,,,,80,,19.68,percent of total billed charges,,,,85,20.91,percent of total billed charges,,,77.7,,19.11,percent of total billed charges,,,95,,23.37,percent of total billed charges,,,60,,14.76,percent of total billed charges,,14.76,23.37,
MYRINGOTOMY BLADE ARROW,100930,CDM,270,RC,,,,,Inpatient,,,24.6,,,,80,,19.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.11,percent of total billed charges,,,95,,23.37,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,23.37,
ARMSTRONG BEVELED GROMMET,100931,CDM,270,RC,,,,,Outpatient,,,39.1,,,,80,,31.28,percent of total billed charges,,,,85,33.24,percent of total billed charges,,,77.7,,30.38,percent of total billed charges,,,95,,37.15,percent of total billed charges,,,60,,23.46,percent of total billed charges,,23.46,37.15,
ARMSTRONG BEVELED GROMMET,100931,CDM,270,RC,,,,,Inpatient,,,39.1,,,,80,,31.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,30.38,percent of total billed charges,,,95,,37.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,37.15,
DURAVENT TUBE 1.27 ULTRASIL,100932,CDM,270,RC,,,,,Outpatient,,,60.6,,,,80,,48.48,percent of total billed charges,,,,85,51.51,percent of total billed charges,,,77.7,,47.09,percent of total billed charges,,,95,,57.57,percent of total billed charges,,,60,,36.36,percent of total billed charges,,36.36,57.57,
DURAVENT TUBE 1.27 ULTRASIL,100932,CDM,270,RC,,,,,Inpatient,,,60.6,,,,80,,48.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,47.09,percent of total billed charges,,,95,,57.57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,57.57,
RICHARDS MODIFIED T-TUBE 1.32X4.8MM,100933,CDM,270,RC,,,,,Outpatient,,,70.4,,,,80,,56.32,percent of total billed charges,,,,85,59.84,percent of total billed charges,,,77.7,,54.7,percent of total billed charges,,,95,,66.88,percent of total billed charges,,,60,,42.24,percent of total billed charges,,42.24,66.88,
RICHARDS MODIFIED T-TUBE 1.32X4.8MM,100933,CDM,270,RC,,,,,Inpatient,,,70.4,,,,80,,56.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,54.7,percent of total billed charges,,,95,,66.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,66.88,
SHEEHY COLLAR BUTTON PACIFIC 1.27MM,100934,CDM,270,RC,,,,,Outpatient,,,25.8,,,,80,,20.64,percent of total billed charges,,,,85,21.93,percent of total billed charges,,,77.7,,20.05,percent of total billed charges,,,95,,24.51,percent of total billed charges,,,60,,15.48,percent of total billed charges,,15.48,24.51,
SHEEHY COLLAR BUTTON PACIFIC 1.27MM,100934,CDM,270,RC,,,,,Inpatient,,,25.8,,,,80,,20.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,20.05,percent of total billed charges,,,95,,24.51,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,24.51,
VENT TUBE FLUOROPLASTIC 12MM X 1.14MM,100935,CDM,270,RC,,,,,Outpatient,,,26.6,,,,80,,21.28,percent of total billed charges,,,,85,22.61,percent of total billed charges,,,77.7,,20.67,percent of total billed charges,,,95,,25.27,percent of total billed charges,,,60,,15.96,percent of total billed charges,,15.96,25.27,
VENT TUBE FLUOROPLASTIC 12MM X 1.14MM,100935,CDM,270,RC,,,,,Inpatient,,,26.6,,,,80,,21.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,20.67,percent of total billed charges,,,95,,25.27,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,25.27,
DIEGO SUCTION/IRRIG TUBING SET,100936,CDM,270,RC,,,,,Outpatient,,,85.3,,,,80,,68.24,percent of total billed charges,,,,85,72.51,percent of total billed charges,,,77.7,,66.28,percent of total billed charges,,,95,,81.04,percent of total billed charges,,,60,,51.18,percent of total billed charges,,51.18,81.04,
DIEGO SUCTION/IRRIG TUBING SET,100936,CDM,270,RC,,,,,Inpatient,,,85.3,,,,80,,68.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,66.28,percent of total billed charges,,,95,,81.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,81.04,
DIEGO OTOLOGY TUBE SET,100937,CDM,270,RC,,,,,Outpatient,,,55.5,,,,80,,44.4,percent of total billed charges,,,,85,47.18,percent of total billed charges,,,77.7,,43.12,percent of total billed charges,,,95,,52.73,percent of total billed charges,,,60,,33.3,percent of total billed charges,,33.3,52.73,
DIEGO OTOLOGY TUBE SET,100937,CDM,270,RC,,,,,Inpatient,,,55.5,,,,80,,44.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,43.12,percent of total billed charges,,,95,,52.73,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,52.73,
DIEGO PWRD DISSECTOR BLADE IRRIG 3.0MM,100938,CDM,270,RC,,,,,Outpatient,,,647.7,,,,80,,518.16,percent of total billed charges,,,,85,550.55,percent of total billed charges,,,77.7,,503.26,percent of total billed charges,,,95,,615.32,percent of total billed charges,,,60,,388.62,percent of total billed charges,,388.62,615.32,
DIEGO PWRD DISSECTOR BLADE IRRIG 3.0MM,100938,CDM,270,RC,,,,,Inpatient,,,647.7,,,,80,,518.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,503.26,percent of total billed charges,,,95,,615.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,615.32,
DIEGO PWRD DISSECTOR BLADE IRRIG 4MM ST,100939,CDM,270,RC,,,,,Outpatient,,,380.7,,,,80,,304.56,percent of total billed charges,,,,85,323.6,percent of total billed charges,,,77.7,,295.8,percent of total billed charges,,,95,,361.67,percent of total billed charges,,,60,,228.42,percent of total billed charges,,228.42,361.67,
DIEGO PWRD DISSECTOR BLADE IRRIG 4MM ST,100939,CDM,270,RC,,,,,Inpatient,,,380.7,,,,80,,304.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,295.8,percent of total billed charges,,,95,,361.67,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,361.67,
DIEGO PWRD DISSECT BLADE LARYNGEAL 3.2MM,100940,CDM,270,RC,,,,,Outpatient,,,885.5,,,,80,,708.4,percent of total billed charges,,,,85,752.68,percent of total billed charges,,,77.7,,688.03,percent of total billed charges,,,95,,841.23,percent of total billed charges,,,60,,531.3,percent of total billed charges,,531.3,841.23,
DIEGO PWRD DISSECT BLADE LARYNGEAL 3.2MM,100940,CDM,270,RC,,,,,Inpatient,,,885.5,,,,80,,708.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,688.03,percent of total billed charges,,,95,,841.23,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,841.23,
DIEGO PWRD DISSECT BLADE LARYNGEAL 4MM,100941,CDM,270,RC,,,,,Outpatient,,,1120.7,,,,80,,896.56,percent of total billed charges,,,,85,952.6,percent of total billed charges,,,77.7,,870.78,percent of total billed charges,,,95,,1064.67,percent of total billed charges,,,60,,672.42,percent of total billed charges,,672.42,1064.67,
DIEGO PWRD DISSECT BLADE LARYNGEAL 4MM,100941,CDM,270,RC,,,,,Inpatient,,,1120.7,,,,80,,896.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,870.78,percent of total billed charges,,,95,,1064.67,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1064.67,
STAPES ROUND CUTTING BURR 1.7MM,100942,CDM,270,RC,,,,,Outpatient,,,306.9,,,,80,,245.52,percent of total billed charges,,,,85,260.87,percent of total billed charges,,,77.7,,238.46,percent of total billed charges,,,95,,291.56,percent of total billed charges,,,60,,184.14,percent of total billed charges,,184.14,291.56,
STAPES ROUND CUTTING BURR 1.7MM,100942,CDM,270,RC,,,,,Inpatient,,,306.9,,,,80,,245.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,238.46,percent of total billed charges,,,95,,291.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,291.56,
STAPES ROUND CUTTING BURR 2.3MM,100943,CDM,270,RC,,,,,Outpatient,,,306.9,,,,80,,245.52,percent of total billed charges,,,,85,260.87,percent of total billed charges,,,77.7,,238.46,percent of total billed charges,,,95,,291.56,percent of total billed charges,,,60,,184.14,percent of total billed charges,,184.14,291.56,
STAPES ROUND CUTTING BURR 2.3MM,100943,CDM,270,RC,,,,,Inpatient,,,306.9,,,,80,,245.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,238.46,percent of total billed charges,,,95,,291.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,291.56,
BLU GLIDE NASAL PACK LARGE,100944,CDM,270,RC,,,,,Outpatient,,,21.6,,,,80,,17.28,percent of total billed charges,,,,85,18.36,percent of total billed charges,,,77.7,,16.78,percent of total billed charges,,,95,,20.52,percent of total billed charges,,,60,,12.96,percent of total billed charges,,12.96,20.52,
BLU GLIDE NASAL PACK LARGE,100944,CDM,270,RC,,,,,Inpatient,,,21.6,,,,80,,17.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,16.78,percent of total billed charges,,,95,,20.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,20.52,
BLU GLIDE NASAL PACK SMALL,100945,CDM,270,RC,,,,,Outpatient,,,17.1,,,,80,,13.68,percent of total billed charges,,,,85,14.54,percent of total billed charges,,,77.7,,13.29,percent of total billed charges,,,95,,16.25,percent of total billed charges,,,60,,10.26,percent of total billed charges,,10.26,16.25,
BLU GLIDE NASAL PACK SMALL,100945,CDM,270,RC,,,,,Inpatient,,,17.1,,,,80,,13.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,13.29,percent of total billed charges,,,95,,16.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,16.25,
SEPRAPACK NASAL PACK BILATERAL 4.0CM,100946,CDM,270,RC,,,,,Outpatient,,,174.2,,,,80,,139.36,percent of total billed charges,,,,85,148.07,percent of total billed charges,,,77.7,,135.35,percent of total billed charges,,,95,,165.49,percent of total billed charges,,,60,,104.52,percent of total billed charges,,104.52,165.49,
SEPRAPACK NASAL PACK BILATERAL 4.0CM,100946,CDM,270,RC,,,,,Inpatient,,,174.2,,,,80,,139.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,135.35,percent of total billed charges,,,95,,165.49,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,165.49,
SEPRAPACK NASAL PACK UNILATERAL 4.OCM,100947,CDM,270,RC,,,,,Outpatient,,,223,,,,80,,178.4,percent of total billed charges,,,,85,189.55,percent of total billed charges,,,77.7,,173.27,percent of total billed charges,,,95,,211.85,percent of total billed charges,,,60,,133.8,percent of total billed charges,,133.8,211.85,
SEPRAPACK NASAL PACK UNILATERAL 4.OCM,100947,CDM,270,RC,,,,,Inpatient,,,223,,,,80,,178.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,173.27,percent of total billed charges,,,95,,211.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,211.85,
SEPRAGEL ENT SYRINGE 2ML,100948,CDM,270,RC,,,,,Outpatient,,,87.1,,,,80,,69.68,percent of total billed charges,,,,85,74.04,percent of total billed charges,,,77.7,,67.68,percent of total billed charges,,,95,,82.75,percent of total billed charges,,,60,,52.26,percent of total billed charges,,52.26,82.75,
SEPRAGEL ENT SYRINGE 2ML,100948,CDM,270,RC,,,,,Inpatient,,,87.1,,,,80,,69.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,67.68,percent of total billed charges,,,95,,82.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,82.75,
SEPTAL BUTTON SILICONE,100949,CDM,270,RC,,,,,Outpatient,,,272.6,,,,80,,218.08,percent of total billed charges,,,,85,231.71,percent of total billed charges,,,77.7,,211.81,percent of total billed charges,,,95,,258.97,percent of total billed charges,,,60,,163.56,percent of total billed charges,,163.56,258.97,
SEPTAL BUTTON SILICONE,100949,CDM,270,RC,,,,,Inpatient,,,272.6,,,,80,,218.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,211.81,percent of total billed charges,,,95,,258.97,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,258.97,
MICRODRIP BACKCHECK PED,100950,CDM,270,RC,,,,,Outpatient,,,13.9,,,,80,,11.12,percent of total billed charges,,,,85,11.82,percent of total billed charges,,,77.7,,10.8,percent of total billed charges,,,95,,13.21,percent of total billed charges,,,60,,8.34,percent of total billed charges,,8.34,13.21,
MICRODRIP BACKCHECK PED,100950,CDM,270,RC,,,,,Inpatient,,,13.9,,,,80,,11.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.8,percent of total billed charges,,,95,,13.21,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.21,
DAVOL CATH 12FR,100955,CDM,270,RC,,,,,Outpatient,,,1.6,,,,80,,1.28,percent of total billed charges,,,,85,1.36,percent of total billed charges,,,77.7,,1.24,percent of total billed charges,,,95,,1.52,percent of total billed charges,,,60,,0.96,percent of total billed charges,,0.96,1.52,
DAVOL CATH 12FR,100955,CDM,270,RC,,,,,Inpatient,,,1.6,,,,80,,1.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.24,percent of total billed charges,,,95,,1.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.52,
NASAL SPLINT THERMOPLASTIC,100961,CDM,270,RC,,,,,Outpatient,,,25.9,,,,80,,20.72,percent of total billed charges,,,,85,22.02,percent of total billed charges,,,77.7,,20.12,percent of total billed charges,,,95,,24.61,percent of total billed charges,,,60,,15.54,percent of total billed charges,,15.54,24.61,
NASAL SPLINT THERMOPLASTIC,100961,CDM,270,RC,,,,,Inpatient,,,25.9,,,,80,,20.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,20.12,percent of total billed charges,,,95,,24.61,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,24.61,
SHAH DRESSING,100962,CDM,270,RC,,,,,Outpatient,,,21.7,,,,80,,17.36,percent of total billed charges,,,,85,18.45,percent of total billed charges,,,77.7,,16.86,percent of total billed charges,,,95,,20.62,percent of total billed charges,,,60,,13.02,percent of total billed charges,,13.02,20.62,
SHAH DRESSING,100962,CDM,270,RC,,,,,Inpatient,,,21.7,,,,80,,17.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,16.86,percent of total billed charges,,,95,,20.62,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,20.62,
NASAL SEPTAL SPLINT,100963,CDM,270,RC,,,,,Outpatient,,,51.7,,,,80,,41.36,percent of total billed charges,,,,85,43.95,percent of total billed charges,,,77.7,,40.17,percent of total billed charges,,,95,,49.12,percent of total billed charges,,,60,,31.02,percent of total billed charges,,31.02,49.12,
NASAL SEPTAL SPLINT,100963,CDM,270,RC,,,,,Inpatient,,,51.7,,,,80,,41.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,40.17,percent of total billed charges,,,95,,49.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,49.12,
BALLOON CATHETER,100964,CDM,270,RC,,,,,Outpatient,,,53.2,,,,80,,42.56,percent of total billed charges,,,,85,45.22,percent of total billed charges,,,77.7,,41.34,percent of total billed charges,,,95,,50.54,percent of total billed charges,,,60,,31.92,percent of total billed charges,,31.92,50.54,
BALLOON CATHETER,100964,CDM,270,RC,,,,,Inpatient,,,53.2,,,,80,,42.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,41.34,percent of total billed charges,,,95,,50.54,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,50.54,
VARI-STIM III,100965,CDM,270,RC,,,,,Outpatient,,,156.3,,,,80,,125.04,percent of total billed charges,,,,85,132.86,percent of total billed charges,,,77.7,,121.45,percent of total billed charges,,,95,,148.49,percent of total billed charges,,,60,,93.78,percent of total billed charges,,93.78,148.49,
VARI-STIM III,100965,CDM,270,RC,,,,,Inpatient,,,156.3,,,,80,,125.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,121.45,percent of total billed charges,,,95,,148.49,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,148.49,
SILICONE SHEETING .5MM,100966,CDM,270,RC,,,,,Outpatient,,,55.2,,,,80,,44.16,percent of total billed charges,,,,85,46.92,percent of total billed charges,,,77.7,,42.89,percent of total billed charges,,,95,,52.44,percent of total billed charges,,,60,,33.12,percent of total billed charges,,33.12,52.44,
SILICONE SHEETING .5MM,100966,CDM,270,RC,,,,,Inpatient,,,55.2,,,,80,,44.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,42.89,percent of total billed charges,,,95,,52.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,52.44,
EPIDISC 8MM,100967,CDM,270,RC,,,,,Outpatient,,,397.3,,,,80,,317.84,percent of total billed charges,,,,85,337.71,percent of total billed charges,,,77.7,,308.7,percent of total billed charges,,,95,,377.44,percent of total billed charges,,,60,,238.38,percent of total billed charges,,238.38,377.44,
EPIDISC 8MM,100967,CDM,270,RC,,,,,Inpatient,,,397.3,,,,80,,317.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,308.7,percent of total billed charges,,,95,,377.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,377.44,
ALLEVYN 4X4 NON ADH DRESSING,100968,CDM,270,RC,,,,,Outpatient,,,11.2,,,,80,,8.96,percent of total billed charges,,,,85,9.52,percent of total billed charges,,,77.7,,8.7,percent of total billed charges,,,95,,10.64,percent of total billed charges,,,60,,6.72,percent of total billed charges,,6.72,10.64,
ALLEVYN 4X4 NON ADH DRESSING,100968,CDM,270,RC,,,,,Inpatient,,,11.2,,,,80,,8.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.7,percent of total billed charges,,,95,,10.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.64,
GELFOAM LARGE SURGIFOAM SPONGE,100969,CDM,270,RC,,,,,Outpatient,,,26.4,,,,80,,21.12,percent of total billed charges,,,,85,22.44,percent of total billed charges,,,77.7,,20.51,percent of total billed charges,,,95,,25.08,percent of total billed charges,,,60,,15.84,percent of total billed charges,,15.84,25.08,
GELFOAM LARGE SURGIFOAM SPONGE,100969,CDM,270,RC,,,,,Inpatient,,,26.4,,,,80,,21.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,20.51,percent of total billed charges,,,95,,25.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,25.08,
GELFOAM SMALL 12-7MM SURGIFOAM SPONGE,100970,CDM,270,RC,,,,,Outpatient,,,26.4,,,,80,,21.12,percent of total billed charges,,,,85,22.44,percent of total billed charges,,,77.7,,20.51,percent of total billed charges,,,95,,25.08,percent of total billed charges,,,60,,15.84,percent of total billed charges,,15.84,25.08,
GELFOAM SMALL 12-7MM SURGIFOAM SPONGE,100970,CDM,270,RC,,,,,Inpatient,,,26.4,,,,80,,21.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,20.51,percent of total billed charges,,,95,,25.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,25.08,
KERLIX SPONGE FLUFF,100972,CDM,270,RC,,,,,Outpatient,,,31.5,,,,80,,25.2,percent of total billed charges,,,,85,26.78,percent of total billed charges,,,77.7,,24.48,percent of total billed charges,,,95,,29.93,percent of total billed charges,,,60,,18.9,percent of total billed charges,,18.9,29.93,
KERLIX SPONGE FLUFF,100972,CDM,270,RC,,,,,Inpatient,,,31.5,,,,80,,25.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,24.48,percent of total billed charges,,,95,,29.93,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,29.93,
SUCTION TUBING 20',100974,CDM,270,RC,,,,,Outpatient,,,5.2,,,,80,,4.16,percent of total billed charges,,,,85,4.42,percent of total billed charges,,,77.7,,4.04,percent of total billed charges,,,95,,4.94,percent of total billed charges,,,60,,3.12,percent of total billed charges,,3.12,4.94,
SUCTION TUBING 20',100974,CDM,270,RC,,,,,Inpatient,,,5.2,,,,80,,4.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.04,percent of total billed charges,,,95,,4.94,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.94,
GAS SAMPLING LINE M/M,100975,CDM,270,RC,,,,,Outpatient,,,3.7,,,,80,,2.96,percent of total billed charges,,,,85,3.15,percent of total billed charges,,,77.7,,2.87,percent of total billed charges,,,95,,3.52,percent of total billed charges,,,60,,2.22,percent of total billed charges,,2.22,3.52,
GAS SAMPLING LINE M/M,100975,CDM,270,RC,,,,,Inpatient,,,3.7,,,,80,,2.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.87,percent of total billed charges,,,95,,3.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.52,
TEGADERM 6 X 8,100979,CDM,270,RC,,,,,Outpatient,,,4.5,,,,80,,3.6,percent of total billed charges,,,,85,3.83,percent of total billed charges,,,77.7,,3.5,percent of total billed charges,,,95,,4.28,percent of total billed charges,,,60,,2.7,percent of total billed charges,,2.7,4.28,
TEGADERM 6 X 8,100979,CDM,270,RC,,,,,Inpatient,,,4.5,,,,80,,3.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.5,percent of total billed charges,,,95,,4.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.28,
PENROSE DRAIN 1 X 12,100982,CDM,270,RC,,,,,Outpatient,,,2.4,,,,80,,1.92,percent of total billed charges,,,,85,2.04,percent of total billed charges,,,77.7,,1.86,percent of total billed charges,,,95,,2.28,percent of total billed charges,,,60,,1.44,percent of total billed charges,,1.44,2.28,
PENROSE DRAIN 1 X 12,100982,CDM,270,RC,,,,,Inpatient,,,2.4,,,,80,,1.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.86,percent of total billed charges,,,95,,2.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.28,
ARM BOARD PADS,100985,CDM,270,RC,,,,,Outpatient,,,8,,,,80,,6.4,percent of total billed charges,,,,85,6.8,percent of total billed charges,,,77.7,,6.22,percent of total billed charges,,,95,,7.6,percent of total billed charges,,,60,,4.8,percent of total billed charges,,4.8,7.6,
ARM BOARD PADS,100985,CDM,270,RC,,,,,Inpatient,,,8,,,,80,,6.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.22,percent of total billed charges,,,95,,7.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.6,
INSTAT HEMOSTAT 1/2GR,100987,CDM,270,RC,,,,,Outpatient,,,297.2,,,,80,,237.76,percent of total billed charges,,,,85,252.62,percent of total billed charges,,,77.7,,230.92,percent of total billed charges,,,95,,282.34,percent of total billed charges,,,60,,178.32,percent of total billed charges,,178.32,282.34,
INSTAT HEMOSTAT 1/2GR,100987,CDM,270,RC,,,,,Inpatient,,,297.2,,,,80,,237.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,230.92,percent of total billed charges,,,95,,282.34,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,282.34,
"PACKING GAUZE 1/2"" IODOFORM",100988,CDM,270,RC,,,,,Outpatient,,,11.1,,,,80,,8.88,percent of total billed charges,,,,85,9.44,percent of total billed charges,,,77.7,,8.62,percent of total billed charges,,,95,,10.55,percent of total billed charges,,,60,,6.66,percent of total billed charges,,6.66,10.55,
"PACKING GAUZE 1/2"" IODOFORM",100988,CDM,270,RC,,,,,Inpatient,,,11.1,,,,80,,8.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.62,percent of total billed charges,,,95,,10.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.55,
"PACKING GAUZE 1"" IODOFORM",100989,CDM,270,RC,,,,,Outpatient,,,11.4,,,,80,,9.12,percent of total billed charges,,,,85,9.69,percent of total billed charges,,,77.7,,8.86,percent of total billed charges,,,95,,10.83,percent of total billed charges,,,60,,6.84,percent of total billed charges,,6.84,10.83,
"PACKING GAUZE 1"" IODOFORM",100989,CDM,270,RC,,,,,Inpatient,,,11.4,,,,80,,9.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.86,percent of total billed charges,,,95,,10.83,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.83,
XEROFORM 4X4 PETROLATUM DRESSING,100990,CDM,270,RC,,,,,Outpatient,,,1.9,,,,80,,1.52,percent of total billed charges,,,,85,1.62,percent of total billed charges,,,77.7,,1.48,percent of total billed charges,,,95,,1.81,percent of total billed charges,,,60,,1.14,percent of total billed charges,,1.14,1.81,
XEROFORM 4X4 PETROLATUM DRESSING,100990,CDM,270,RC,,,,,Inpatient,,,1.9,,,,80,,1.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.48,percent of total billed charges,,,95,,1.81,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.81,
XEROFORM 1X8 PETROLATUM DRESSING,100991,CDM,270,RC,,,,,Outpatient,,,2.2,,,,80,,1.76,percent of total billed charges,,,,85,1.87,percent of total billed charges,,,77.7,,1.71,percent of total billed charges,,,95,,2.09,percent of total billed charges,,,60,,1.32,percent of total billed charges,,1.32,2.09,
XEROFORM 1X8 PETROLATUM DRESSING,100991,CDM,270,RC,,,,,Inpatient,,,2.2,,,,80,,1.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.71,percent of total billed charges,,,95,,2.09,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.09,
DERMABOND PROPEN,100992,CDM,270,RC,,,,,Outpatient,,,62.4,,,,80,,49.92,percent of total billed charges,,,,85,53.04,percent of total billed charges,,,77.7,,48.48,percent of total billed charges,,,95,,59.28,percent of total billed charges,,,60,,37.44,percent of total billed charges,,37.44,59.28,
DERMABOND PROPEN,100992,CDM,270,RC,,,,,Inpatient,,,62.4,,,,80,,49.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,48.48,percent of total billed charges,,,95,,59.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,59.28,
HUMIDIFIER 340ML PREFILL,100995,CDM,270,RC,,,,,Outpatient,,,4.4,,,,80,,3.52,percent of total billed charges,,,,85,3.74,percent of total billed charges,,,77.7,,3.42,percent of total billed charges,,,95,,4.18,percent of total billed charges,,,60,,2.64,percent of total billed charges,,2.64,4.18,
HUMIDIFIER 340ML PREFILL,100995,CDM,270,RC,,,,,Inpatient,,,4.4,,,,80,,3.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.42,percent of total billed charges,,,95,,4.18,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.18,
HUMIDIFIER 650ML PREFILL,100996,CDM,270,RC,,,,,Outpatient,,,7,,,,80,,5.6,percent of total billed charges,,,,85,5.95,percent of total billed charges,,,77.7,,5.44,percent of total billed charges,,,95,,6.65,percent of total billed charges,,,60,,4.2,percent of total billed charges,,4.2,6.65,
HUMIDIFIER 650ML PREFILL,100996,CDM,270,RC,,,,,Inpatient,,,7,,,,80,,5.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.44,percent of total billed charges,,,95,,6.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.65,
ENDOTRACH TUBE 3.5 CUFFED,100997,CDM,270,RC,,,,,Outpatient,,,5.1,,,,80,,4.08,percent of total billed charges,,,,85,4.34,percent of total billed charges,,,77.7,,3.96,percent of total billed charges,,,95,,4.85,percent of total billed charges,,,60,,3.06,percent of total billed charges,,3.06,4.85,
ENDOTRACH TUBE 3.5 CUFFED,100997,CDM,270,RC,,,,,Inpatient,,,5.1,,,,80,,4.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.96,percent of total billed charges,,,95,,4.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.85,
ENDOTRACH TUBE 4.0 UNCUFFED,100998,CDM,270,RC,,,,,Outpatient,,,3.4,,,,80,,2.72,percent of total billed charges,,,,85,2.89,percent of total billed charges,,,77.7,,2.64,percent of total billed charges,,,95,,3.23,percent of total billed charges,,,60,,2.04,percent of total billed charges,,2.04,3.23,
ENDOTRACH TUBE 4.0 UNCUFFED,100998,CDM,270,RC,,,,,Inpatient,,,3.4,,,,80,,2.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.64,percent of total billed charges,,,95,,3.23,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.23,
ENDOTRACH TUBE 4.5 UNCUFFED,100999,CDM,270,RC,,,,,Outpatient,,,3.2,,,,80,,2.56,percent of total billed charges,,,,85,2.72,percent of total billed charges,,,77.7,,2.49,percent of total billed charges,,,95,,3.04,percent of total billed charges,,,60,,1.92,percent of total billed charges,,1.92,3.04,
ENDOTRACH TUBE 4.5 UNCUFFED,100999,CDM,270,RC,,,,,Inpatient,,,3.2,,,,80,,2.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.49,percent of total billed charges,,,95,,3.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.04,
ENDOTRACH TUBE 5.0 UNCUFFED,101000,CDM,270,RC,,,,,Outpatient,,,3.4,,,,80,,2.72,percent of total billed charges,,,,85,2.89,percent of total billed charges,,,77.7,,2.64,percent of total billed charges,,,95,,3.23,percent of total billed charges,,,60,,2.04,percent of total billed charges,,2.04,3.23,
ENDOTRACH TUBE 5.0 UNCUFFED,101000,CDM,270,RC,,,,,Inpatient,,,3.4,,,,80,,2.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.64,percent of total billed charges,,,95,,3.23,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.23,
ENDOTRACH TUBE 5.5 UNCUFFED,101001,CDM,270,RC,,,,,Outpatient,,,3.4,,,,80,,2.72,percent of total billed charges,,,,85,2.89,percent of total billed charges,,,77.7,,2.64,percent of total billed charges,,,95,,3.23,percent of total billed charges,,,60,,2.04,percent of total billed charges,,2.04,3.23,
ENDOTRACH TUBE 5.5 UNCUFFED,101001,CDM,270,RC,,,,,Inpatient,,,3.4,,,,80,,2.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.64,percent of total billed charges,,,95,,3.23,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.23,
AIRWAY ORAL 50MM LT BLUE,101002,CDM,270,RC,,,,,Outpatient,,,0.8,,,,80,,0.64,percent of total billed charges,,,,85,0.68,percent of total billed charges,,,77.7,,0.62,percent of total billed charges,,,95,,0.76,percent of total billed charges,,,60,,0.48,percent of total billed charges,,0.48,0.76,
AIRWAY ORAL 50MM LT BLUE,101002,CDM,270,RC,,,,,Inpatient,,,0.8,,,,80,,0.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.62,percent of total billed charges,,,95,,0.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,0.76,
AIRWAY ORAL 60MM BLACK,101003,CDM,270,RC,,,,,Outpatient,,,0.8,,,,80,,0.64,percent of total billed charges,,,,85,0.68,percent of total billed charges,,,77.7,,0.62,percent of total billed charges,,,95,,0.76,percent of total billed charges,,,60,,0.48,percent of total billed charges,,0.48,0.76,
AIRWAY ORAL 60MM BLACK,101003,CDM,270,RC,,,,,Inpatient,,,0.8,,,,80,,0.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.62,percent of total billed charges,,,95,,0.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,0.76,
ZZZAIRWAY ORAL 100MM,101004,CDM,270,RC,,,,,Outpatient,,,0.8,,,,80,,0.64,percent of total billed charges,,,,85,0.68,percent of total billed charges,,,77.7,,0.62,percent of total billed charges,,,95,,0.76,percent of total billed charges,,,60,,0.48,percent of total billed charges,,0.48,0.76,
ZZZAIRWAY ORAL 100MM,101004,CDM,270,RC,,,,,Inpatient,,,0.8,,,,80,,0.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.62,percent of total billed charges,,,95,,0.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,0.76,
ENDOTRACH TUBE 6.0 UNCUFFED,101005,CDM,270,RC,,,,,Outpatient,,,3.4,,,,80,,2.72,percent of total billed charges,,,,85,2.89,percent of total billed charges,,,77.7,,2.64,percent of total billed charges,,,95,,3.23,percent of total billed charges,,,60,,2.04,percent of total billed charges,,2.04,3.23,
ENDOTRACH TUBE 6.0 UNCUFFED,101005,CDM,270,RC,,,,,Inpatient,,,3.4,,,,80,,2.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.64,percent of total billed charges,,,95,,3.23,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.23,
ENDOTRACH TUBE 6.5 UNCUFFED,101006,CDM,270,RC,,,,,Outpatient,,,8,,,,80,,6.4,percent of total billed charges,,,,85,6.8,percent of total billed charges,,,77.7,,6.22,percent of total billed charges,,,95,,7.6,percent of total billed charges,,,60,,4.8,percent of total billed charges,,4.8,7.6,
ENDOTRACH TUBE 6.5 UNCUFFED,101006,CDM,270,RC,,,,,Inpatient,,,8,,,,80,,6.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.22,percent of total billed charges,,,95,,7.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.6,
ARM SLING XSMALL PADDED,101007,CDM,270,RC,,,,,Outpatient,,,7.3,,,,80,,5.84,percent of total billed charges,,,,85,6.21,percent of total billed charges,,,77.7,,5.67,percent of total billed charges,,,95,,6.94,percent of total billed charges,,,60,,4.38,percent of total billed charges,,4.38,6.94,
ARM SLING XSMALL PADDED,101007,CDM,270,RC,,,,,Inpatient,,,7.3,,,,80,,5.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.67,percent of total billed charges,,,95,,6.94,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.94,
"SUCTION COAG HAND CONTROL 10F 6""",101008,CDM,270,RC,,,,,Outpatient,,,31.9,,,,80,,25.52,percent of total billed charges,,,,85,27.12,percent of total billed charges,,,77.7,,24.79,percent of total billed charges,,,95,,30.31,percent of total billed charges,,,60,,19.14,percent of total billed charges,,19.14,30.31,
"SUCTION COAG HAND CONTROL 10F 6""",101008,CDM,270,RC,,,,,Inpatient,,,31.9,,,,80,,25.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,24.79,percent of total billed charges,,,95,,30.31,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,30.31,
CORNEAL PROTECTORS,101009,CDM,270,RC,,,,,Outpatient,,,5.3,,,,80,,4.24,percent of total billed charges,,,,85,4.51,percent of total billed charges,,,77.7,,4.12,percent of total billed charges,,,95,,5.04,percent of total billed charges,,,60,,3.18,percent of total billed charges,,3.18,5.04,
CORNEAL PROTECTORS,101009,CDM,270,RC,,,,,Inpatient,,,5.3,,,,80,,4.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.12,percent of total billed charges,,,95,,5.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.04,
SKIN PREP WET TRAY PVP,101010,CDM,270,RC,,,,,Outpatient,,,25.5,,,,80,,20.4,percent of total billed charges,,,,85,21.68,percent of total billed charges,,,77.7,,19.81,percent of total billed charges,,,95,,24.23,percent of total billed charges,,,60,,15.3,percent of total billed charges,,15.3,24.23,
SKIN PREP WET TRAY PVP,101010,CDM,270,RC,,,,,Inpatient,,,25.5,,,,80,,20.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.81,percent of total billed charges,,,95,,24.23,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,24.23,
MASS EYE/EAR PISTON 4.5MM X .6MM,101011,CDM,270,RC,,,,,Outpatient,,,464.3,,,,80,,371.44,percent of total billed charges,,,,85,394.66,percent of total billed charges,,,77.7,,360.76,percent of total billed charges,,,95,,441.09,percent of total billed charges,,,60,,278.58,percent of total billed charges,,278.58,441.09,
MASS EYE/EAR PISTON 4.5MM X .6MM,101011,CDM,270,RC,,,,,Inpatient,,,464.3,,,,80,,371.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,360.76,percent of total billed charges,,,95,,441.09,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,441.09,
DORNHOFFER HAPEX PORP,101012,CDM,270,RC,,,,,Outpatient,,,1348.4,,,,80,,1078.72,percent of total billed charges,,,,85,1146.14,percent of total billed charges,,,77.7,,1047.71,percent of total billed charges,,,95,,1280.98,percent of total billed charges,,,60,,809.04,percent of total billed charges,,809.04,1280.98,
DORNHOFFER HAPEX PORP,101012,CDM,270,RC,,,,,Inpatient,,,1348.4,,,,80,,1078.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1047.71,percent of total billed charges,,,95,,1280.98,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1280.98,
DORNHOFFER HAPEX TORP,101013,CDM,270,RC,,,,,Outpatient,,,1386.1,,,,80,,1108.88,percent of total billed charges,,,,85,1178.19,percent of total billed charges,,,77.7,,1077,percent of total billed charges,,,95,,1316.8,percent of total billed charges,,,60,,831.66,percent of total billed charges,,831.66,1316.8,
DORNHOFFER HAPEX TORP,101013,CDM,270,RC,,,,,Inpatient,,,1386.1,,,,80,,1108.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1077,percent of total billed charges,,,95,,1316.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1316.8,
STOMACH TUBE NG 10 FR,101015,CDM,270,RC,,,,,Outpatient,,,5.5,,,,80,,4.4,percent of total billed charges,,,,85,4.68,percent of total billed charges,,,77.7,,4.27,percent of total billed charges,,,95,,5.23,percent of total billed charges,,,60,,3.3,percent of total billed charges,,3.3,5.23,
STOMACH TUBE NG 10 FR,101015,CDM,270,RC,,,,,Inpatient,,,5.5,,,,80,,4.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.27,percent of total billed charges,,,95,,5.23,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.23,
VALVED SPRING TEE ADAPTER,101017,CDM,270,RC,,,,,Outpatient,,,21.4,,,,80,,17.12,percent of total billed charges,,,,85,18.19,percent of total billed charges,,,77.7,,16.63,percent of total billed charges,,,95,,20.33,percent of total billed charges,,,60,,12.84,percent of total billed charges,,12.84,20.33,
VALVED SPRING TEE ADAPTER,101017,CDM,270,RC,,,,,Inpatient,,,21.4,,,,80,,17.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,16.63,percent of total billed charges,,,95,,20.33,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,20.33,
BACTERIAL FILTER,101018,CDM,270,RC,,,,,Outpatient,,,7,,,,80,,5.6,percent of total billed charges,,,,85,5.95,percent of total billed charges,,,77.7,,5.44,percent of total billed charges,,,95,,6.65,percent of total billed charges,,,60,,4.2,percent of total billed charges,,4.2,6.65,
BACTERIAL FILTER,101018,CDM,270,RC,,,,,Inpatient,,,7,,,,80,,5.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.44,percent of total billed charges,,,95,,6.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.65,
IMF PRECUT WIRE,101021,CDM,270,RC,,,,,Outpatient,,,25.2,,,,80,,20.16,percent of total billed charges,,,,85,21.42,percent of total billed charges,,,77.7,,19.58,percent of total billed charges,,,95,,23.94,percent of total billed charges,,,60,,15.12,percent of total billed charges,,15.12,23.94,
IMF PRECUT WIRE,101021,CDM,270,RC,,,,,Inpatient,,,25.2,,,,80,,20.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.58,percent of total billed charges,,,95,,23.94,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,23.94,
SUCTION CATHETER 18 FR W/G,101023,CDM,270,RC,,,,,Outpatient,,,2.2,,,,80,,1.76,percent of total billed charges,,,,85,1.87,percent of total billed charges,,,77.7,,1.71,percent of total billed charges,,,95,,2.09,percent of total billed charges,,,60,,1.32,percent of total billed charges,,1.32,2.09,
SUCTION CATHETER 18 FR W/G,101023,CDM,270,RC,,,,,Inpatient,,,2.2,,,,80,,1.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.71,percent of total billed charges,,,95,,2.09,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.09,
SUCTION CATHETER 12 FR W/G,101024,CDM,270,RC,,,,,Outpatient,,,2.1,,,,80,,1.68,percent of total billed charges,,,,85,1.79,percent of total billed charges,,,77.7,,1.63,percent of total billed charges,,,95,,2,percent of total billed charges,,,60,,1.26,percent of total billed charges,,1.26,2,
SUCTION CATHETER 12 FR W/G,101024,CDM,270,RC,,,,,Inpatient,,,2.1,,,,80,,1.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.63,percent of total billed charges,,,95,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2,
"MESH ULTRAPRO 3"" FLAT",101027,CDM,278,RC,C1781,HCPCS,,,Outpatient,,,198.3,,,,80,,158.64,percent of total billed charges,,,,85,168.56,percent of total billed charges,,,77.7,,154.08,percent of total billed charges,,,95,,188.39,percent of total billed charges,,,60,,118.98,percent of total billed charges,,118.98,188.39,
"MESH ULTRAPRO 3"" FLAT",101027,CDM,278,RC,C1781,HCPCS,,,Inpatient,,,198.3,,,,80,,158.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,154.08,percent of total billed charges,,,95,,188.39,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,188.39,
NEBULIZER W/ADAPTER PREFILL 440ML,101028,CDM,270,RC,,,,,Outpatient,,,8.3,,,,80,,6.64,percent of total billed charges,,,,85,7.06,percent of total billed charges,,,77.7,,6.45,percent of total billed charges,,,95,,7.89,percent of total billed charges,,,60,,4.98,percent of total billed charges,,4.98,7.89,
NEBULIZER W/ADAPTER PREFILL 440ML,101028,CDM,270,RC,,,,,Inpatient,,,8.3,,,,80,,6.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.45,percent of total billed charges,,,95,,7.89,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.89,
FACE TENT,101030,CDM,270,RC,,,,,Outpatient,,,2.6,,,,80,,2.08,percent of total billed charges,,,,85,2.21,percent of total billed charges,,,77.7,,2.02,percent of total billed charges,,,95,,2.47,percent of total billed charges,,,60,,1.56,percent of total billed charges,,1.56,2.47,
FACE TENT,101030,CDM,270,RC,,,,,Inpatient,,,2.6,,,,80,,2.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.02,percent of total billed charges,,,95,,2.47,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.47,
PERIGUARD CREAM 3.5 OZ,101034,CDM,270,RC,,,,,Outpatient,,,7.7,,,,80,,6.16,percent of total billed charges,,,,85,6.55,percent of total billed charges,,,77.7,,5.98,percent of total billed charges,,,95,,7.32,percent of total billed charges,,,60,,4.62,percent of total billed charges,,4.62,7.32,
PERIGUARD CREAM 3.5 OZ,101034,CDM,270,RC,,,,,Inpatient,,,7.7,,,,80,,6.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.98,percent of total billed charges,,,95,,7.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.32,
MEPITEL 2X3 DRESSING,101037,CDM,270,RC,,,,,Outpatient,,,12.3,,,,80,,9.84,percent of total billed charges,,,,85,10.46,percent of total billed charges,,,77.7,,9.56,percent of total billed charges,,,95,,11.69,percent of total billed charges,,,60,,7.38,percent of total billed charges,,7.38,11.69,
MEPITEL 2X3 DRESSING,101037,CDM,270,RC,,,,,Inpatient,,,12.3,,,,80,,9.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.56,percent of total billed charges,,,95,,11.69,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.69,
NEEDLE SPINAL 27 X 3 1/2 QUINCKE,101038,CDM,270,RC,,,,,Outpatient,,,6.6,,,,80,,5.28,percent of total billed charges,,,,85,5.61,percent of total billed charges,,,77.7,,5.13,percent of total billed charges,,,95,,6.27,percent of total billed charges,,,60,,3.96,percent of total billed charges,,3.96,6.27,
NEEDLE SPINAL 27 X 3 1/2 QUINCKE,101038,CDM,270,RC,,,,,Inpatient,,,6.6,,,,80,,5.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.13,percent of total billed charges,,,95,,6.27,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.27,
SHILEY TRACH #6 CUFFED,101039,CDM,270,RC,,,,,Outpatient,,,272.1,,,,80,,217.68,percent of total billed charges,,,,85,231.29,percent of total billed charges,,,77.7,,211.42,percent of total billed charges,,,95,,258.5,percent of total billed charges,,,60,,163.26,percent of total billed charges,,163.26,258.5,
SHILEY TRACH #6 CUFFED,101039,CDM,270,RC,,,,,Inpatient,,,272.1,,,,80,,217.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,211.42,percent of total billed charges,,,95,,258.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,258.5,
SHILEY TRACH #8 CUFFED,101040,CDM,270,RC,,,,,Outpatient,,,266.1,,,,80,,212.88,percent of total billed charges,,,,85,226.19,percent of total billed charges,,,77.7,,206.76,percent of total billed charges,,,95,,252.8,percent of total billed charges,,,60,,159.66,percent of total billed charges,,159.66,252.8,
SHILEY TRACH #8 CUFFED,101040,CDM,270,RC,,,,,Inpatient,,,266.1,,,,80,,212.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,206.76,percent of total billed charges,,,95,,252.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,252.8,
SHILEY TRACH #4 CUFFED,101041,CDM,270,RC,,,,,Outpatient,,,272.1,,,,80,,217.68,percent of total billed charges,,,,85,231.29,percent of total billed charges,,,77.7,,211.42,percent of total billed charges,,,95,,258.5,percent of total billed charges,,,60,,163.26,percent of total billed charges,,163.26,258.5,
SHILEY TRACH #4 CUFFED,101041,CDM,270,RC,,,,,Inpatient,,,272.1,,,,80,,217.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,211.42,percent of total billed charges,,,95,,258.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,258.5,
AQUACEL AG SILVER DRESSING 4X4 CONVATEC,101046,CDM,270,RC,,,,,Outpatient,,,25.8,,,,80,,20.64,percent of total billed charges,,,,85,21.93,percent of total billed charges,,,77.7,,20.05,percent of total billed charges,,,95,,24.51,percent of total billed charges,,,60,,15.48,percent of total billed charges,,15.48,24.51,
AQUACEL AG SILVER DRESSING 4X4 CONVATEC,101046,CDM,270,RC,,,,,Inpatient,,,25.8,,,,80,,20.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,20.05,percent of total billed charges,,,95,,24.51,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,24.51,
NASAL AIRWAY 30FR,101047,CDM,270,RC,,,,,Outpatient,,,11.4,,,,80,,9.12,percent of total billed charges,,,,85,9.69,percent of total billed charges,,,77.7,,8.86,percent of total billed charges,,,95,,10.83,percent of total billed charges,,,60,,6.84,percent of total billed charges,,6.84,10.83,
NASAL AIRWAY 30FR,101047,CDM,270,RC,,,,,Inpatient,,,11.4,,,,80,,9.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.86,percent of total billed charges,,,95,,10.83,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.83,
SUCTION CANISTER 3000CC,101049,CDM,270,RC,,,,,Outpatient,,,7.3,,,,80,,5.84,percent of total billed charges,,,,85,6.21,percent of total billed charges,,,77.7,,5.67,percent of total billed charges,,,95,,6.94,percent of total billed charges,,,60,,4.38,percent of total billed charges,,4.38,6.94,
SUCTION CANISTER 3000CC,101049,CDM,270,RC,,,,,Inpatient,,,7.3,,,,80,,5.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.67,percent of total billed charges,,,95,,6.94,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.94,
SPECIMEN ADAPTER,101050,CDM,270,RC,,,,,Outpatient,,,12,,,,80,,9.6,percent of total billed charges,,,,85,10.2,percent of total billed charges,,,77.7,,9.32,percent of total billed charges,,,95,,11.4,percent of total billed charges,,,60,,7.2,percent of total billed charges,,7.2,11.4,
SPECIMEN ADAPTER,101050,CDM,270,RC,,,,,Inpatient,,,12,,,,80,,9.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.32,percent of total billed charges,,,95,,11.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.4,
IV EXTENDER TWIN SITE,101052,CDM,270,RC,,,,,Outpatient,,,8.6,,,,80,,6.88,percent of total billed charges,,,,85,7.31,percent of total billed charges,,,77.7,,6.68,percent of total billed charges,,,95,,8.17,percent of total billed charges,,,60,,5.16,percent of total billed charges,,5.16,8.17,
IV EXTENDER TWIN SITE,101052,CDM,270,RC,,,,,Inpatient,,,8.6,,,,80,,6.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.68,percent of total billed charges,,,95,,8.17,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,8.17,
OXIMAX ADULT/PED SENSOR,101060,CDM,270,RC,,,,,Outpatient,,,34,,,,80,,27.2,percent of total billed charges,,,,85,28.9,percent of total billed charges,,,77.7,,26.42,percent of total billed charges,,,95,,32.3,percent of total billed charges,,,60,,20.4,percent of total billed charges,,20.4,32.3,
OXIMAX ADULT/PED SENSOR,101060,CDM,270,RC,,,,,Inpatient,,,34,,,,80,,27.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,26.42,percent of total billed charges,,,95,,32.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,32.3,
Pulse Ox Wrap disposable,101061,CDM,270,RC,,,,,Outpatient,,,19.3,,,,80,,15.44,percent of total billed charges,,,,85,16.41,percent of total billed charges,,,77.7,,15,percent of total billed charges,,,95,,18.34,percent of total billed charges,,,60,,11.58,percent of total billed charges,,11.58,18.34,
Pulse Ox Wrap disposable,101061,CDM,270,RC,,,,,Inpatient,,,19.3,,,,80,,15.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,15,percent of total billed charges,,,95,,18.34,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,18.34,
ANESTHESIA CIRCUIT EXTENDER,101062,CDM,270,RC,,,,,Outpatient,,,9.7,,,,80,,7.76,percent of total billed charges,,,,85,8.25,percent of total billed charges,,,77.7,,7.54,percent of total billed charges,,,95,,9.22,percent of total billed charges,,,60,,5.82,percent of total billed charges,,5.82,9.22,
ANESTHESIA CIRCUIT EXTENDER,101062,CDM,270,RC,,,,,Inpatient,,,9.7,,,,80,,7.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.54,percent of total billed charges,,,95,,9.22,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.22,
PERFORMA TRAK SMALL,101065,CDM,270,RC,,,,,Outpatient,,,0.5,,,,80,,0.4,percent of total billed charges,,,,85,0.43,percent of total billed charges,,,77.7,,0.39,percent of total billed charges,,,95,,0.48,percent of total billed charges,,,60,,0.3,percent of total billed charges,,0.3,0.48,
PERFORMA TRAK SMALL,101065,CDM,270,RC,,,,,Inpatient,,,0.5,,,,80,,0.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.39,percent of total billed charges,,,95,,0.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,0.48,
PERFORMA TRAK LG,101067,CDM,270,RC,,,,,Outpatient,,,108.2,,,,80,,86.56,percent of total billed charges,,,,85,91.97,percent of total billed charges,,,77.7,,84.07,percent of total billed charges,,,95,,102.79,percent of total billed charges,,,60,,64.92,percent of total billed charges,,64.92,102.79,
PERFORMA TRAK LG,101067,CDM,270,RC,,,,,Inpatient,,,108.2,,,,80,,86.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,84.07,percent of total billed charges,,,95,,102.79,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,102.79,
EXTERNAL CATHETER - MED FREEDOM 28MM,101071,CDM,270,RC,,,,,Outpatient,,,4.1,,,,80,,3.28,percent of total billed charges,,,,85,3.49,percent of total billed charges,,,77.7,,3.19,percent of total billed charges,,,95,,3.9,percent of total billed charges,,,60,,2.46,percent of total billed charges,,2.46,3.9,
EXTERNAL CATHETER - MED FREEDOM 28MM,101071,CDM,270,RC,,,,,Inpatient,,,4.1,,,,80,,3.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.19,percent of total billed charges,,,95,,3.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.9,
SPIDER NET NAKAO,101072,CDM,270,RC,,,,,Outpatient,,,280.9,,,,80,,224.72,percent of total billed charges,,,,85,238.77,percent of total billed charges,,,77.7,,218.26,percent of total billed charges,,,95,,266.86,percent of total billed charges,,,60,,168.54,percent of total billed charges,,168.54,266.86,
SPIDER NET NAKAO,101072,CDM,270,RC,,,,,Inpatient,,,280.9,,,,80,,224.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,218.26,percent of total billed charges,,,95,,266.86,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,266.86,
SUCTION CATH 5/6 FR,101073,CDM,270,RC,,,,,Outpatient,,,1.4,,,,80,,1.12,percent of total billed charges,,,,85,1.19,percent of total billed charges,,,77.7,,1.09,percent of total billed charges,,,95,,1.33,percent of total billed charges,,,60,,0.84,percent of total billed charges,,0.84,1.33,
SUCTION CATH 5/6 FR,101073,CDM,270,RC,,,,,Inpatient,,,1.4,,,,80,,1.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.09,percent of total billed charges,,,95,,1.33,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.33,
ALLEVYN 4X4 THIN NON ADH DRESSING,101075,CDM,270,RC,,,,,Outpatient,,,11.1,,,,80,,8.88,percent of total billed charges,,,,85,9.44,percent of total billed charges,,,77.7,,8.62,percent of total billed charges,,,95,,10.55,percent of total billed charges,,,60,,6.66,percent of total billed charges,,6.66,10.55,
ALLEVYN 4X4 THIN NON ADH DRESSING,101075,CDM,270,RC,,,,,Inpatient,,,11.1,,,,80,,8.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.62,percent of total billed charges,,,95,,10.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.55,
PERCUSSOR INFANT/PED,101078,CDM,270,RC,,,,,Outpatient,,,18.2,,,,80,,14.56,percent of total billed charges,,,,85,15.47,percent of total billed charges,,,77.7,,14.14,percent of total billed charges,,,95,,17.29,percent of total billed charges,,,60,,10.92,percent of total billed charges,,10.92,17.29,
PERCUSSOR INFANT/PED,101078,CDM,270,RC,,,,,Inpatient,,,18.2,,,,80,,14.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.14,percent of total billed charges,,,95,,17.29,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.29,
CLAVE EXT SET LOCKING END,101080,CDM,270,RC,,,,,Outpatient,,,7,,,,80,,5.6,percent of total billed charges,,,,85,5.95,percent of total billed charges,,,77.7,,5.44,percent of total billed charges,,,95,,6.65,percent of total billed charges,,,60,,4.2,percent of total billed charges,,4.2,6.65,
CLAVE EXT SET LOCKING END,101080,CDM,270,RC,,,,,Inpatient,,,7,,,,80,,5.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.44,percent of total billed charges,,,95,,6.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.65,
ALLKARE BARRIER WIPE,101090,CDM,270,RC,,,,,Outpatient,,,0.5,,,,80,,0.4,percent of total billed charges,,,,85,0.43,percent of total billed charges,,,77.7,,0.39,percent of total billed charges,,,95,,0.48,percent of total billed charges,,,60,,0.3,percent of total billed charges,,0.3,0.48,
ALLKARE BARRIER WIPE,101090,CDM,270,RC,,,,,Inpatient,,,0.5,,,,80,,0.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.39,percent of total billed charges,,,95,,0.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,0.48,
ANESTHESIA CONNECTOR STRAIGHT W/PORT,101092,CDM,270,RC,,,,,Outpatient,,,1.9,,,,80,,1.52,percent of total billed charges,,,,85,1.62,percent of total billed charges,,,77.7,,1.48,percent of total billed charges,,,95,,1.81,percent of total billed charges,,,60,,1.14,percent of total billed charges,,1.14,1.81,
ANESTHESIA CONNECTOR STRAIGHT W/PORT,101092,CDM,270,RC,,,,,Inpatient,,,1.9,,,,80,,1.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.48,percent of total billed charges,,,95,,1.81,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.81,
NEBULIZER AERO ECLIPSE II BAN,101094,CDM,270,RC,,,,,Outpatient,,,16.6,,,,80,,13.28,percent of total billed charges,,,,85,14.11,percent of total billed charges,,,77.7,,12.9,percent of total billed charges,,,95,,15.77,percent of total billed charges,,,60,,9.96,percent of total billed charges,,9.96,15.77,
NEBULIZER AERO ECLIPSE II BAN,101094,CDM,270,RC,,,,,Inpatient,,,16.6,,,,80,,13.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.9,percent of total billed charges,,,95,,15.77,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.77,
DISPERSIVE GROUND PEDIATRIC >30#,101096,CDM,270,RC,,,,,Outpatient,,,16.8,,,,80,,13.44,percent of total billed charges,,,,85,14.28,percent of total billed charges,,,77.7,,13.05,percent of total billed charges,,,95,,15.96,percent of total billed charges,,,60,,10.08,percent of total billed charges,,10.08,15.96,
DISPERSIVE GROUND PEDIATRIC >30#,101096,CDM,270,RC,,,,,Inpatient,,,16.8,,,,80,,13.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,13.05,percent of total billed charges,,,95,,15.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.96,
ENDO BABCOK 10MM,101099,CDM,270,RC,,,,,Outpatient,,,43,,,,80,,34.4,percent of total billed charges,,,,85,36.55,percent of total billed charges,,,77.7,,33.41,percent of total billed charges,,,95,,40.85,percent of total billed charges,,,60,,25.8,percent of total billed charges,,25.8,40.85,
ENDO BABCOK 10MM,101099,CDM,270,RC,,,,,Inpatient,,,43,,,,80,,34.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,33.41,percent of total billed charges,,,95,,40.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,40.85,
PROTACK 5MM 30 TACK,101100,CDM,270,RC,,,,,Outpatient,,,1931.2,,,,80,,1544.96,percent of total billed charges,,,,85,1641.52,percent of total billed charges,,,77.7,,1500.54,percent of total billed charges,,,95,,1834.64,percent of total billed charges,,,60,,1158.72,percent of total billed charges,,1158.72,1834.64,
PROTACK 5MM 30 TACK,101100,CDM,270,RC,,,,,Inpatient,,,1931.2,,,,80,,1544.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1500.54,percent of total billed charges,,,95,,1834.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1834.64,
ENDO CLINCH II 5MM,101101,CDM,270,RC,,,,,Outpatient,,,43.8,,,,80,,35.04,percent of total billed charges,,,,85,37.23,percent of total billed charges,,,77.7,,34.03,percent of total billed charges,,,95,,41.61,percent of total billed charges,,,60,,26.28,percent of total billed charges,,26.28,41.61,
ENDO CLINCH II 5MM,101101,CDM,270,RC,,,,,Inpatient,,,43.8,,,,80,,35.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,34.03,percent of total billed charges,,,95,,41.61,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,41.61,
ENDOSTITCH 2-0 SILK SUTURE,101102,CDM,270,RC,,,,,Outpatient,,,11.4,,,,80,,9.12,percent of total billed charges,,,,85,9.69,percent of total billed charges,,,77.7,,8.86,percent of total billed charges,,,95,,10.83,percent of total billed charges,,,60,,6.84,percent of total billed charges,,6.84,10.83,
ENDOSTITCH 2-0 SILK SUTURE,101102,CDM,270,RC,,,,,Inpatient,,,11.4,,,,80,,9.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.86,percent of total billed charges,,,95,,10.83,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.83,
ENDOSTITCH 2-0 BRALON SUTURE,101103,CDM,270,RC,,,,,Outpatient,,,42.5,,,,80,,34,percent of total billed charges,,,,85,36.13,percent of total billed charges,,,77.7,,33.02,percent of total billed charges,,,95,,40.38,percent of total billed charges,,,60,,25.5,percent of total billed charges,,25.5,40.38,
ENDOSTITCH 2-0 BRALON SUTURE,101103,CDM,270,RC,,,,,Inpatient,,,42.5,,,,80,,34,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,33.02,percent of total billed charges,,,95,,40.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,40.38,
CANNULA E-Z WRAP,101104,CDM,270,RC,,,,,Outpatient,,,2,,,,80,,1.6,percent of total billed charges,,,,85,1.7,percent of total billed charges,,,77.7,,1.55,percent of total billed charges,,,95,,1.9,percent of total billed charges,,,60,,1.2,percent of total billed charges,,1.2,1.9,
CANNULA E-Z WRAP,101104,CDM,270,RC,,,,,Inpatient,,,2,,,,80,,1.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.55,percent of total billed charges,,,95,,1.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.9,
NASAL AIRWAY 26FR,101108,CDM,270,RC,,,,,Outpatient,,,11.4,,,,80,,9.12,percent of total billed charges,,,,85,9.69,percent of total billed charges,,,77.7,,8.86,percent of total billed charges,,,95,,10.83,percent of total billed charges,,,60,,6.84,percent of total billed charges,,6.84,10.83,
NASAL AIRWAY 26FR,101108,CDM,270,RC,,,,,Inpatient,,,11.4,,,,80,,9.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.86,percent of total billed charges,,,95,,10.83,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.83,
NASAL AIRWAY 28FR,101109,CDM,270,RC,,,,,Outpatient,,,11.4,,,,80,,9.12,percent of total billed charges,,,,85,9.69,percent of total billed charges,,,77.7,,8.86,percent of total billed charges,,,95,,10.83,percent of total billed charges,,,60,,6.84,percent of total billed charges,,6.84,10.83,
NASAL AIRWAY 28FR,101109,CDM,270,RC,,,,,Inpatient,,,11.4,,,,80,,9.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.86,percent of total billed charges,,,95,,10.83,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.83,
NASAL AIRWAY 32FR,101110,CDM,270,RC,,,,,Outpatient,,,11.4,,,,80,,9.12,percent of total billed charges,,,,85,9.69,percent of total billed charges,,,77.7,,8.86,percent of total billed charges,,,95,,10.83,percent of total billed charges,,,60,,6.84,percent of total billed charges,,6.84,10.83,
NASAL AIRWAY 32FR,101110,CDM,270,RC,,,,,Inpatient,,,11.4,,,,80,,9.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.86,percent of total billed charges,,,95,,10.83,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.83,
NASAL AIRWAY 34FR LF PVC,101111,CDM,270,RC,,,,,Outpatient,,,6.2,,,,80,,4.96,percent of total billed charges,,,,85,5.27,percent of total billed charges,,,77.7,,4.82,percent of total billed charges,,,95,,5.89,percent of total billed charges,,,60,,3.72,percent of total billed charges,,3.72,5.89,
NASAL AIRWAY 34FR LF PVC,101111,CDM,270,RC,,,,,Inpatient,,,6.2,,,,80,,4.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.82,percent of total billed charges,,,95,,5.89,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.89,
NASAL AIRWAY 36FR LF PVC,101112,CDM,270,RC,,,,,Outpatient,,,6.3,,,,80,,5.04,percent of total billed charges,,,,85,5.36,percent of total billed charges,,,77.7,,4.9,percent of total billed charges,,,95,,5.99,percent of total billed charges,,,60,,3.78,percent of total billed charges,,3.78,5.99,
NASAL AIRWAY 36FR LF PVC,101112,CDM,270,RC,,,,,Inpatient,,,6.3,,,,80,,5.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.9,percent of total billed charges,,,95,,5.99,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.99,
ARM BOARD BENDABLE PED,101113,CDM,270,RC,,,,,Outpatient,,,5.9,,,,80,,4.72,percent of total billed charges,,,,85,5.02,percent of total billed charges,,,77.7,,4.58,percent of total billed charges,,,95,,5.61,percent of total billed charges,,,60,,3.54,percent of total billed charges,,3.54,5.61,
ARM BOARD BENDABLE PED,101113,CDM,270,RC,,,,,Inpatient,,,5.9,,,,80,,4.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.58,percent of total billed charges,,,95,,5.61,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.61,
SUCTION TUBING 12',101114,CDM,270,RC,,,,,Outpatient,,,3.2,,,,80,,2.56,percent of total billed charges,,,,85,2.72,percent of total billed charges,,,77.7,,2.49,percent of total billed charges,,,95,,3.04,percent of total billed charges,,,60,,1.92,percent of total billed charges,,1.92,3.04,
SUCTION TUBING 12',101114,CDM,270,RC,,,,,Inpatient,,,3.2,,,,80,,2.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.49,percent of total billed charges,,,95,,3.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.04,
MESH PERFIX PLUG BARD,101116,CDM,278,RC,C1781,HCPCS,,,Outpatient,,,220.3,,,,80,,176.24,percent of total billed charges,,,,85,187.26,percent of total billed charges,,,77.7,,171.17,percent of total billed charges,,,95,,209.29,percent of total billed charges,,,60,,132.18,percent of total billed charges,,132.18,209.29,
MESH PERFIX PLUG BARD,101116,CDM,278,RC,C1781,HCPCS,,,Inpatient,,,220.3,,,,80,,176.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,171.17,percent of total billed charges,,,95,,209.29,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,209.29,
INTRODUCER ET PED 10FR COUDE,101118,CDM,270,RC,,,,,Outpatient,,,34.5,,,,80,,27.6,percent of total billed charges,,,,85,29.33,percent of total billed charges,,,77.7,,26.81,percent of total billed charges,,,95,,32.78,percent of total billed charges,,,60,,20.7,percent of total billed charges,,20.7,32.78,
INTRODUCER ET PED 10FR COUDE,101118,CDM,270,RC,,,,,Inpatient,,,34.5,,,,80,,27.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,26.81,percent of total billed charges,,,95,,32.78,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,32.78,
INTRODUCER ET ADULT 15 FR COUDE,101119,CDM,270,RC,,,,,Outpatient,,,18.2,,,,80,,14.56,percent of total billed charges,,,,85,15.47,percent of total billed charges,,,77.7,,14.14,percent of total billed charges,,,95,,17.29,percent of total billed charges,,,60,,10.92,percent of total billed charges,,10.92,17.29,
INTRODUCER ET ADULT 15 FR COUDE,101119,CDM,270,RC,,,,,Inpatient,,,18.2,,,,80,,14.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.14,percent of total billed charges,,,95,,17.29,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.29,
TRACH TUBE HOLDER,101122,CDM,270,RC,,,,,Outpatient,,,11.2,,,,80,,8.96,percent of total billed charges,,,,85,9.52,percent of total billed charges,,,77.7,,8.7,percent of total billed charges,,,95,,10.64,percent of total billed charges,,,60,,6.72,percent of total billed charges,,6.72,10.64,
TRACH TUBE HOLDER,101122,CDM,270,RC,,,,,Inpatient,,,11.2,,,,80,,8.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.7,percent of total billed charges,,,95,,10.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.64,
ENDO PADDLE RETRACTOR 12MM,101123,CDM,270,RC,,,,,Outpatient,,,427.9,,,,80,,342.32,percent of total billed charges,,,,85,363.72,percent of total billed charges,,,77.7,,332.48,percent of total billed charges,,,95,,406.51,percent of total billed charges,,,60,,256.74,percent of total billed charges,,256.74,406.51,
ENDO PADDLE RETRACTOR 12MM,101123,CDM,270,RC,,,,,Inpatient,,,427.9,,,,80,,342.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,332.48,percent of total billed charges,,,95,,406.51,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,406.51,
STAPLER GIA ENDO 12MM,101124,CDM,270,RC,,,,,Outpatient,,,404.5,,,,80,,323.6,percent of total billed charges,,,,85,343.83,percent of total billed charges,,,77.7,,314.3,percent of total billed charges,,,95,,384.28,percent of total billed charges,,,60,,242.7,percent of total billed charges,,242.7,384.28,
STAPLER GIA ENDO 12MM,101124,CDM,270,RC,,,,,Inpatient,,,404.5,,,,80,,323.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,314.3,percent of total billed charges,,,95,,384.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,384.28,
HEMOVAC WOUND DRAIN 10FR X .125,101125,CDM,270,RC,,,,,Outpatient,,,42.1,,,,80,,33.68,percent of total billed charges,,,,85,35.79,percent of total billed charges,,,77.7,,32.71,percent of total billed charges,,,95,,40,percent of total billed charges,,,60,,25.26,percent of total billed charges,,25.26,40,
HEMOVAC WOUND DRAIN 10FR X .125,101125,CDM,270,RC,,,,,Inpatient,,,42.1,,,,80,,33.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,32.71,percent of total billed charges,,,95,,40,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,40,
HEMOVAC WOUND DRAIN 19FR X .25,101126,CDM,270,RC,,,,,Outpatient,,,39.5,,,,80,,31.6,percent of total billed charges,,,,85,33.58,percent of total billed charges,,,77.7,,30.69,percent of total billed charges,,,95,,37.53,percent of total billed charges,,,60,,23.7,percent of total billed charges,,23.7,37.53,
HEMOVAC WOUND DRAIN 19FR X .25,101126,CDM,270,RC,,,,,Inpatient,,,39.5,,,,80,,31.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,30.69,percent of total billed charges,,,95,,37.53,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,37.53,
STAPLER RELOAD 60 2.5MM GIA II,101130,CDM,270,RC,,,,,Outpatient,,,3.1,,,,80,,2.48,percent of total billed charges,,,,85,2.64,percent of total billed charges,,,77.7,,2.41,percent of total billed charges,,,95,,2.95,percent of total billed charges,,,60,,1.86,percent of total billed charges,,1.86,2.95,
STAPLER RELOAD 60 2.5MM GIA II,101130,CDM,270,RC,,,,,Inpatient,,,3.1,,,,80,,2.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.41,percent of total billed charges,,,95,,2.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.95,
STAPLER RELOAD 60 3.5MM GIA II,101131,CDM,270,RC,,,,,Outpatient,,,69.9,,,,80,,55.92,percent of total billed charges,,,,85,59.42,percent of total billed charges,,,77.7,,54.31,percent of total billed charges,,,95,,66.41,percent of total billed charges,,,60,,41.94,percent of total billed charges,,41.94,66.41,
STAPLER RELOAD 60 3.5MM GIA II,101131,CDM,270,RC,,,,,Inpatient,,,69.9,,,,80,,55.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,54.31,percent of total billed charges,,,95,,66.41,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,66.41,
STAPLER RELOAD 30 3.5MM GIA,101132,CDM,270,RC,,,,,Outpatient,,,344.7,,,,80,,275.76,percent of total billed charges,,,,85,293,percent of total billed charges,,,77.7,,267.83,percent of total billed charges,,,95,,327.47,percent of total billed charges,,,60,,206.82,percent of total billed charges,,206.82,327.47,
STAPLER RELOAD 30 3.5MM GIA,101132,CDM,270,RC,,,,,Inpatient,,,344.7,,,,80,,275.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,267.83,percent of total billed charges,,,95,,327.47,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,327.47,
STAPLER RELOAD 45 3.5MM GIA,101133,CDM,270,RC,,,,,Outpatient,,,12.9,,,,80,,10.32,percent of total billed charges,,,,85,10.97,percent of total billed charges,,,77.7,,10.02,percent of total billed charges,,,95,,12.26,percent of total billed charges,,,60,,7.74,percent of total billed charges,,7.74,12.26,
STAPLER RELOAD 45 3.5MM GIA,101133,CDM,270,RC,,,,,Inpatient,,,12.9,,,,80,,10.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.02,percent of total billed charges,,,95,,12.26,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,12.26,
STAPLER RELOAD 45 2.5MM GIA,101134,CDM,270,RC,,,,,Outpatient,,,0.4,,,,80,,0.32,percent of total billed charges,,,,85,0.34,percent of total billed charges,,,77.7,,0.31,percent of total billed charges,,,95,,0.38,percent of total billed charges,,,60,,0.24,percent of total billed charges,,0.24,0.38,
STAPLER RELOAD 45 2.5MM GIA,101134,CDM,270,RC,,,,,Inpatient,,,0.4,,,,80,,0.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.31,percent of total billed charges,,,95,,0.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,0.38,
SHILEY TRACH #6 UNCUFFED,101135,CDM,270,RC,,,,,Outpatient,,,188.6,,,,80,,150.88,percent of total billed charges,,,,85,160.31,percent of total billed charges,,,77.7,,146.54,percent of total billed charges,,,95,,179.17,percent of total billed charges,,,60,,113.16,percent of total billed charges,,113.16,179.17,
SHILEY TRACH #6 UNCUFFED,101135,CDM,270,RC,,,,,Inpatient,,,188.6,,,,80,,150.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,146.54,percent of total billed charges,,,95,,179.17,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,179.17,
SHILEY TRACH #8 UNCUFFED,101136,CDM,270,RC,,,,,Outpatient,,,188.6,,,,80,,150.88,percent of total billed charges,,,,85,160.31,percent of total billed charges,,,77.7,,146.54,percent of total billed charges,,,95,,179.17,percent of total billed charges,,,60,,113.16,percent of total billed charges,,113.16,179.17,
SHILEY TRACH #8 UNCUFFED,101136,CDM,270,RC,,,,,Inpatient,,,188.6,,,,80,,150.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,146.54,percent of total billed charges,,,95,,179.17,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,179.17,
ZZZTRACH/ET TUBE HOLDER ADULT,101137,CDM,270,RC,,,,,Outpatient,,,10.4,,,,80,,8.32,percent of total billed charges,,,,85,8.84,percent of total billed charges,,,77.7,,8.08,percent of total billed charges,,,95,,9.88,percent of total billed charges,,,60,,6.24,percent of total billed charges,,6.24,9.88,
ZZZTRACH/ET TUBE HOLDER ADULT,101137,CDM,270,RC,,,,,Inpatient,,,10.4,,,,80,,8.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.08,percent of total billed charges,,,95,,9.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.88,
"SURGITIE CHROMIC LOOP 21"" 5CM",101139,CDM,270,RC,,,,,Outpatient,,,144.8,,,,80,,115.84,percent of total billed charges,,,,85,123.08,percent of total billed charges,,,77.7,,112.51,percent of total billed charges,,,95,,137.56,percent of total billed charges,,,60,,86.88,percent of total billed charges,,86.88,137.56,
"SURGITIE CHROMIC LOOP 21"" 5CM",101139,CDM,270,RC,,,,,Inpatient,,,144.8,,,,80,,115.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,112.51,percent of total billed charges,,,95,,137.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,137.56,
MESH 3D MAX RIGHT MED DAVOL,101140,CDM,278,RC,C1781,HCPCS,,,Outpatient,,,560,,,,80,,448,percent of total billed charges,,,,85,476,percent of total billed charges,,,77.7,,435.12,percent of total billed charges,,,95,,532,percent of total billed charges,,,60,,336,percent of total billed charges,,336,532,
MESH 3D MAX RIGHT MED DAVOL,101140,CDM,278,RC,C1781,HCPCS,,,Inpatient,,,560,,,,80,,448,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,435.12,percent of total billed charges,,,95,,532,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,532,
TVT SECURE,101142,CDM,270,RC,,,,,Outpatient,,,605.8,,,,80,,484.64,percent of total billed charges,,,,85,514.93,percent of total billed charges,,,77.7,,470.71,percent of total billed charges,,,95,,575.51,percent of total billed charges,,,60,,363.48,percent of total billed charges,,363.48,575.51,
TVT SECURE,101142,CDM,270,RC,,,,,Inpatient,,,605.8,,,,80,,484.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,470.71,percent of total billed charges,,,95,,575.51,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,575.51,
KNEE SPLINT HINGED MEDIUM,101143,CDM,274,RC,L1812,HCPCS,,,Outpatient,,,60.6,,,,80,,48.48,percent of total billed charges,,,,85,51.51,percent of total billed charges,,,77.7,,47.09,percent of total billed charges,,,95,,57.57,percent of total billed charges,,,60,,36.36,percent of total billed charges,,36.36,57.57,
KNEE SPLINT HINGED MEDIUM,101143,CDM,274,RC,L1812,HCPCS,,,Inpatient,,,60.6,,,,80,,48.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,47.09,percent of total billed charges,,,95,,57.57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,57.57,
KNEE SPLINT HINGED LARGE,101144,CDM,274,RC,L1812,HCPCS,,,Outpatient,,,70.5,,,,80,,56.4,percent of total billed charges,,,,85,59.93,percent of total billed charges,,,77.7,,54.78,percent of total billed charges,,,95,,66.98,percent of total billed charges,,,60,,42.3,percent of total billed charges,,42.3,66.98,
KNEE SPLINT HINGED LARGE,101144,CDM,274,RC,L1812,HCPCS,,,Inpatient,,,70.5,,,,80,,56.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,54.78,percent of total billed charges,,,95,,66.98,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,66.98,
L1812 KNEE SPLINT HINGED XLARGE,101145,CDM,274,RC,L1812,HCPCS,,,Outpatient,,,60.6,,,,80,,48.48,percent of total billed charges,,,,85,51.51,percent of total billed charges,,,77.7,,47.09,percent of total billed charges,,,95,,57.57,percent of total billed charges,,,60,,36.36,percent of total billed charges,,36.36,57.57,
L1812 KNEE SPLINT HINGED XLARGE,101145,CDM,274,RC,L1812,HCPCS,,,Inpatient,,,60.6,,,,80,,48.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,47.09,percent of total billed charges,,,95,,57.57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,57.57,
MESH BARD PRESHAPED 1.8 X 4  DAVOL,101146,CDM,278,RC,C1781,HCPCS,,,Outpatient,,,395.5,,,,80,,316.4,percent of total billed charges,,,,85,336.18,percent of total billed charges,,,77.7,,307.3,percent of total billed charges,,,95,,375.73,percent of total billed charges,,,60,,237.3,percent of total billed charges,,237.3,375.73,
MESH BARD PRESHAPED 1.8 X 4  DAVOL,101146,CDM,278,RC,C1781,HCPCS,,,Inpatient,,,395.5,,,,80,,316.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,307.3,percent of total billed charges,,,95,,375.73,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,375.73,
MESH BARD PRESHAPED 2.4 X 5.4  DAVOL,101147,CDM,278,RC,C1781,HCPCS,,,Outpatient,,,442.2,,,,80,,353.76,percent of total billed charges,,,,85,375.87,percent of total billed charges,,,77.7,,343.59,percent of total billed charges,,,95,,420.09,percent of total billed charges,,,60,,265.32,percent of total billed charges,,265.32,420.09,
MESH BARD PRESHAPED 2.4 X 5.4  DAVOL,101147,CDM,278,RC,C1781,HCPCS,,,Inpatient,,,442.2,,,,80,,353.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,343.59,percent of total billed charges,,,95,,420.09,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,420.09,
MESH TINTRAL XB 30 X 30 X 20,101149,CDM,278,RC,C1781,HCPCS,,,Outpatient,,,9992.5,,,,80,,7994,percent of total billed charges,,,,85,8493.63,percent of total billed charges,,,77.7,,7764.17,percent of total billed charges,,,95,,9492.88,percent of total billed charges,,,60,,5995.5,percent of total billed charges,,5995.5,9492.88,
MESH TINTRAL XB 30 X 30 X 20,101149,CDM,278,RC,C1781,HCPCS,,,Inpatient,,,9992.5,,,,80,,7994,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7764.17,percent of total billed charges,,,95,,9492.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9492.88,
INSUFFLATION TUBING,101150,CDM,270,RC,,,,,Outpatient,,,25.7,,,,80,,20.56,percent of total billed charges,,,,85,21.85,percent of total billed charges,,,77.7,,19.97,percent of total billed charges,,,95,,24.42,percent of total billed charges,,,60,,15.42,percent of total billed charges,,15.42,24.42,
INSUFFLATION TUBING,101150,CDM,270,RC,,,,,Inpatient,,,25.7,,,,80,,20.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.97,percent of total billed charges,,,95,,24.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,24.42,
ENDOGATOR TUBING,101151,CDM,270,RC,,,,,Outpatient,,,56.1,,,,80,,44.88,percent of total billed charges,,,,85,47.69,percent of total billed charges,,,77.7,,43.59,percent of total billed charges,,,95,,53.3,percent of total billed charges,,,60,,33.66,percent of total billed charges,,33.66,53.3,
ENDOGATOR TUBING,101151,CDM,270,RC,,,,,Inpatient,,,56.1,,,,80,,44.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,43.59,percent of total billed charges,,,95,,53.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,53.3,
ELECTRODE LOOP 15MM X 12MM,101152,CDM,270,RC,,,,,Outpatient,,,48.2,,,,80,,38.56,percent of total billed charges,,,,85,40.97,percent of total billed charges,,,77.7,,37.45,percent of total billed charges,,,95,,45.79,percent of total billed charges,,,60,,28.92,percent of total billed charges,,28.92,45.79,
ELECTRODE LOOP 15MM X 12MM,101152,CDM,270,RC,,,,,Inpatient,,,48.2,,,,80,,38.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,37.45,percent of total billed charges,,,95,,45.79,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,45.79,
ELECTRODE LOOP 20MM X 12MM,101153,CDM,270,RC,,,,,Outpatient,,,34.9,,,,80,,27.92,percent of total billed charges,,,,85,29.67,percent of total billed charges,,,77.7,,27.12,percent of total billed charges,,,95,,33.16,percent of total billed charges,,,60,,20.94,percent of total billed charges,,20.94,33.16,
ELECTRODE LOOP 20MM X 12MM,101153,CDM,270,RC,,,,,Inpatient,,,34.9,,,,80,,27.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,27.12,percent of total billed charges,,,95,,33.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,33.16,
HUBER 20G X 1 1/2 IN,101154,CDM,270,RC,,,,,Outpatient,,,13.8,,,,80,,11.04,percent of total billed charges,,,,85,11.73,percent of total billed charges,,,77.7,,10.72,percent of total billed charges,,,95,,13.11,percent of total billed charges,,,60,,8.28,percent of total billed charges,,8.28,13.11,
HUBER 20G X 1 1/2 IN,101154,CDM,270,RC,,,,,Inpatient,,,13.8,,,,80,,11.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.72,percent of total billed charges,,,95,,13.11,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.11,
ELECTRODE LOOP VAL LAB 15MM X 12MM,101155,CDM,270,RC,,,,,Outpatient,,,68.6,,,,80,,54.88,percent of total billed charges,,,,85,58.31,percent of total billed charges,,,77.7,,53.3,percent of total billed charges,,,95,,65.17,percent of total billed charges,,,60,,41.16,percent of total billed charges,,41.16,65.17,
ELECTRODE LOOP VAL LAB 15MM X 12MM,101155,CDM,270,RC,,,,,Inpatient,,,68.6,,,,80,,54.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,53.3,percent of total billed charges,,,95,,65.17,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,65.17,
ELECTRODE LOOP VAL LAB 20MM X 12MM,101156,CDM,270,RC,,,,,Outpatient,,,68.6,,,,80,,54.88,percent of total billed charges,,,,85,58.31,percent of total billed charges,,,77.7,,53.3,percent of total billed charges,,,95,,65.17,percent of total billed charges,,,60,,41.16,percent of total billed charges,,41.16,65.17,
ELECTRODE LOOP VAL LAB 20MM X 12MM,101156,CDM,270,RC,,,,,Inpatient,,,68.6,,,,80,,54.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,53.3,percent of total billed charges,,,95,,65.17,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,65.17,
HUBER 20G X 1,101157,CDM,270,RC,,,,,Outpatient,,,13.8,,,,80,,11.04,percent of total billed charges,,,,85,11.73,percent of total billed charges,,,77.7,,10.72,percent of total billed charges,,,95,,13.11,percent of total billed charges,,,60,,8.28,percent of total billed charges,,8.28,13.11,
HUBER 20G X 1,101157,CDM,270,RC,,,,,Inpatient,,,13.8,,,,80,,11.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.72,percent of total billed charges,,,95,,13.11,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.11,
ENDO CATCH,101161,CDM,270,RC,,,,,Outpatient,,,4.8,,,,80,,3.84,percent of total billed charges,,,,85,4.08,percent of total billed charges,,,77.7,,3.73,percent of total billed charges,,,95,,4.56,percent of total billed charges,,,60,,2.88,percent of total billed charges,,2.88,4.56,
ENDO CATCH,101161,CDM,270,RC,,,,,Inpatient,,,4.8,,,,80,,3.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.73,percent of total billed charges,,,95,,4.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.56,
NIM ELECTRODES,101162,CDM,270,RC,,,,,Outpatient,,,437.5,,,,80,,350,percent of total billed charges,,,,85,371.88,percent of total billed charges,,,77.7,,339.94,percent of total billed charges,,,95,,415.63,percent of total billed charges,,,60,,262.5,percent of total billed charges,,262.5,415.63,
NIM ELECTRODES,101162,CDM,270,RC,,,,,Inpatient,,,437.5,,,,80,,350,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,339.94,percent of total billed charges,,,95,,415.63,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,415.63,
NIM STIM PROBE,101163,CDM,270,RC,,,,,Outpatient,,,353.5,,,,80,,282.8,percent of total billed charges,,,,85,300.48,percent of total billed charges,,,77.7,,274.67,percent of total billed charges,,,95,,335.83,percent of total billed charges,,,60,,212.1,percent of total billed charges,,212.1,335.83,
NIM STIM PROBE,101163,CDM,270,RC,,,,,Inpatient,,,353.5,,,,80,,282.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,274.67,percent of total billed charges,,,95,,335.83,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,335.83,
STOMACH TUBE NG 8 FR,101164,CDM,270,RC,,,,,Outpatient,,,13.5,,,,80,,10.8,percent of total billed charges,,,,85,11.48,percent of total billed charges,,,77.7,,10.49,percent of total billed charges,,,95,,12.83,percent of total billed charges,,,60,,8.1,percent of total billed charges,,8.1,12.83,
STOMACH TUBE NG 8 FR,101164,CDM,270,RC,,,,,Inpatient,,,13.5,,,,80,,10.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.49,percent of total billed charges,,,95,,12.83,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,12.83,
TEGASORB 4 X 4,101168,CDM,270,RC,,,,,Outpatient,,,14.9,,,,80,,11.92,percent of total billed charges,,,,85,12.67,percent of total billed charges,,,77.7,,11.58,percent of total billed charges,,,95,,14.16,percent of total billed charges,,,60,,8.94,percent of total billed charges,,8.94,14.16,
TEGASORB 4 X 4,101168,CDM,270,RC,,,,,Inpatient,,,14.9,,,,80,,11.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.58,percent of total billed charges,,,95,,14.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,14.16,
SHILEY TRACH #4 UNCUFFED FENESTRATED,101170,CDM,270,RC,,,,,Outpatient,,,159.8,,,,80,,127.84,percent of total billed charges,,,,85,135.83,percent of total billed charges,,,77.7,,124.16,percent of total billed charges,,,95,,151.81,percent of total billed charges,,,60,,95.88,percent of total billed charges,,95.88,151.81,
SHILEY TRACH #4 UNCUFFED FENESTRATED,101170,CDM,270,RC,,,,,Inpatient,,,159.8,,,,80,,127.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,124.16,percent of total billed charges,,,95,,151.81,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,151.81,
VAC SIMPLACE MED DRESSING,101172,CDM,270,RC,,,,,Outpatient,,,165.1,,,,80,,132.08,percent of total billed charges,,,,85,140.34,percent of total billed charges,,,77.7,,128.28,percent of total billed charges,,,95,,156.85,percent of total billed charges,,,60,,99.06,percent of total billed charges,,99.06,156.85,
VAC SIMPLACE MED DRESSING,101172,CDM,270,RC,,,,,Inpatient,,,165.1,,,,80,,132.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,128.28,percent of total billed charges,,,95,,156.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,156.85,
HEEL PILLOW PLAID POSEY,101173,CDM,270,RC,,,,,Outpatient,,,50.5,,,,80,,40.4,percent of total billed charges,,,,85,42.93,percent of total billed charges,,,77.7,,39.24,percent of total billed charges,,,95,,47.98,percent of total billed charges,,,60,,30.3,percent of total billed charges,,30.3,47.98,
HEEL PILLOW PLAID POSEY,101173,CDM,270,RC,,,,,Inpatient,,,50.5,,,,80,,40.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,39.24,percent of total billed charges,,,95,,47.98,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,47.98,
ACTICOAT SILVER DRESSING 4X5,101180,CDM,270,RC,,,,,Outpatient,,,40.6,,,,80,,32.48,percent of total billed charges,,,,85,34.51,percent of total billed charges,,,77.7,,31.55,percent of total billed charges,,,95,,38.57,percent of total billed charges,,,60,,24.36,percent of total billed charges,,24.36,38.57,
ACTICOAT SILVER DRESSING 4X5,101180,CDM,270,RC,,,,,Inpatient,,,40.6,,,,80,,32.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,31.55,percent of total billed charges,,,95,,38.57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,38.57,
LIGACLIP LG MULTI CLIP APPLIER,101182,CDM,270,RC,,,,,Outpatient,,,14.6,,,,80,,11.68,percent of total billed charges,,,,85,12.41,percent of total billed charges,,,77.7,,11.34,percent of total billed charges,,,95,,13.87,percent of total billed charges,,,60,,8.76,percent of total billed charges,,8.76,13.87,
LIGACLIP LG MULTI CLIP APPLIER,101182,CDM,270,RC,,,,,Inpatient,,,14.6,,,,80,,11.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.34,percent of total billed charges,,,95,,13.87,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.87,
LIGACLIP MED MULTI CLIP APPLIER,101183,CDM,270,RC,,,,,Outpatient,,,0.7,,,,80,,0.56,percent of total billed charges,,,,85,0.6,percent of total billed charges,,,77.7,,0.54,percent of total billed charges,,,95,,0.67,percent of total billed charges,,,60,,0.42,percent of total billed charges,,0.42,0.67,
LIGACLIP MED MULTI CLIP APPLIER,101183,CDM,270,RC,,,,,Inpatient,,,0.7,,,,80,,0.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.54,percent of total billed charges,,,95,,0.67,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,0.67,
VAC GRANU FOAM DRESSING SMALL BLACK,101192,CDM,270,RC,,,,,Outpatient,,,124.8,,,,80,,99.84,percent of total billed charges,,,,85,106.08,percent of total billed charges,,,77.7,,96.97,percent of total billed charges,,,95,,118.56,percent of total billed charges,,,60,,74.88,percent of total billed charges,,74.88,118.56,
VAC GRANU FOAM DRESSING SMALL BLACK,101192,CDM,270,RC,,,,,Inpatient,,,124.8,,,,80,,99.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,96.97,percent of total billed charges,,,95,,118.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,118.56,
VAC WHITE FOAM ONLY SMALL,101196,CDM,270,RC,,,,,Outpatient,,,35.8,,,,80,,28.64,percent of total billed charges,,,,85,30.43,percent of total billed charges,,,77.7,,27.82,percent of total billed charges,,,95,,34.01,percent of total billed charges,,,60,,21.48,percent of total billed charges,,21.48,34.01,
VAC WHITE FOAM ONLY SMALL,101196,CDM,270,RC,,,,,Inpatient,,,35.8,,,,80,,28.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,27.82,percent of total billed charges,,,95,,34.01,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,34.01,
PIC LINE 4FR,101197,CDM,278,RC,C1751,HCPCS,,,Outpatient,,,300.4,,,,80,,240.32,percent of total billed charges,,,,85,255.34,percent of total billed charges,,,77.7,,233.41,percent of total billed charges,,,95,,285.38,percent of total billed charges,,,60,,180.24,percent of total billed charges,,180.24,285.38,
PIC LINE 4FR,101197,CDM,278,RC,C1751,HCPCS,,,Inpatient,,,300.4,,,,80,,240.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,233.41,percent of total billed charges,,,95,,285.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,285.38,
VAC Y CONNECTOR,101198,CDM,270,RC,,,,,Outpatient,,,6.6,,,,80,,5.28,percent of total billed charges,,,,85,5.61,percent of total billed charges,,,77.7,,5.13,percent of total billed charges,,,95,,6.27,percent of total billed charges,,,60,,3.96,percent of total billed charges,,3.96,6.27,
VAC Y CONNECTOR,101198,CDM,270,RC,,,,,Inpatient,,,6.6,,,,80,,5.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.13,percent of total billed charges,,,95,,6.27,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.27,
KALTOSTAT 2GM ROPE  CONVATEC,101199,CDM,270,RC,,,,,Outpatient,,,15.1,,,,80,,12.08,percent of total billed charges,,,,85,12.84,percent of total billed charges,,,77.7,,11.73,percent of total billed charges,,,95,,14.35,percent of total billed charges,,,60,,9.06,percent of total billed charges,,9.06,14.35,
KALTOSTAT 2GM ROPE  CONVATEC,101199,CDM,270,RC,,,,,Inpatient,,,15.1,,,,80,,12.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.73,percent of total billed charges,,,95,,14.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,14.35,
ROTH NET POLYP,101201,CDM,270,RC,,,,,Outpatient,,,38.8,,,,80,,31.04,percent of total billed charges,,,,85,32.98,percent of total billed charges,,,77.7,,30.15,percent of total billed charges,,,95,,36.86,percent of total billed charges,,,60,,23.28,percent of total billed charges,,23.28,36.86,
ROTH NET POLYP,101201,CDM,270,RC,,,,,Inpatient,,,38.8,,,,80,,31.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,30.15,percent of total billed charges,,,95,,36.86,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,36.86,
MICROBORE LINE B BRAUN,101206,CDM,270,RC,,,,,Outpatient,,,4.7,,,,80,,3.76,percent of total billed charges,,,,85,4,percent of total billed charges,,,77.7,,3.65,percent of total billed charges,,,95,,4.47,percent of total billed charges,,,60,,2.82,percent of total billed charges,,2.82,4.47,
MICROBORE LINE B BRAUN,101206,CDM,270,RC,,,,,Inpatient,,,4.7,,,,80,,3.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.65,percent of total billed charges,,,95,,4.47,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.47,
HELITENE .5GR ABSORBABLE COLLAGEN,101207,CDM,270,RC,,,,,Outpatient,,,414.6,,,,80,,331.68,percent of total billed charges,,,,85,352.41,percent of total billed charges,,,77.7,,322.14,percent of total billed charges,,,95,,393.87,percent of total billed charges,,,60,,248.76,percent of total billed charges,,248.76,393.87,
HELITENE .5GR ABSORBABLE COLLAGEN,101207,CDM,270,RC,,,,,Inpatient,,,414.6,,,,80,,331.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,322.14,percent of total billed charges,,,95,,393.87,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,393.87,
DUO DERM CGF 4 X 4,101208,CDM,270,RC,,,,,Outpatient,,,10.2,,,,80,,8.16,percent of total billed charges,,,,85,8.67,percent of total billed charges,,,77.7,,7.93,percent of total billed charges,,,95,,9.69,percent of total billed charges,,,60,,6.12,percent of total billed charges,,6.12,9.69,
DUO DERM CGF 4 X 4,101208,CDM,270,RC,,,,,Inpatient,,,10.2,,,,80,,8.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.93,percent of total billed charges,,,95,,9.69,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.69,
DUO DERM EXTRA THIN 4 X 4,101209,CDM,270,RC,,,,,Outpatient,,,6.4,,,,80,,5.12,percent of total billed charges,,,,85,5.44,percent of total billed charges,,,77.7,,4.97,percent of total billed charges,,,95,,6.08,percent of total billed charges,,,60,,3.84,percent of total billed charges,,3.84,6.08,
DUO DERM EXTRA THIN 4 X 4,101209,CDM,270,RC,,,,,Inpatient,,,6.4,,,,80,,5.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.97,percent of total billed charges,,,95,,6.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.08,
VAC BRIDGE DRESSING XLG,101213,CDM,270,RC,,,,,Outpatient,,,193.2,,,,80,,154.56,percent of total billed charges,,,,85,164.22,percent of total billed charges,,,77.7,,150.12,percent of total billed charges,,,95,,183.54,percent of total billed charges,,,60,,115.92,percent of total billed charges,,115.92,183.54,
VAC BRIDGE DRESSING XLG,101213,CDM,270,RC,,,,,Inpatient,,,193.2,,,,80,,154.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,150.12,percent of total billed charges,,,95,,183.54,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,183.54,
"VASELINE GAUZE 6"" X 36"" KENDALL",101214,CDM,270,RC,,,,,Outpatient,,,4.1,,,,80,,3.28,percent of total billed charges,,,,85,3.49,percent of total billed charges,,,77.7,,3.19,percent of total billed charges,,,95,,3.9,percent of total billed charges,,,60,,2.46,percent of total billed charges,,2.46,3.9,
"VASELINE GAUZE 6"" X 36"" KENDALL",101214,CDM,270,RC,,,,,Inpatient,,,4.1,,,,80,,3.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.19,percent of total billed charges,,,95,,3.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.9,
RELIEVA SINUS GUIDE CATHETER,101215,CDM,278,RC,C1887,HCPCS,,,Outpatient,,,1295,,,,80,,1036,percent of total billed charges,,,,85,1100.75,percent of total billed charges,,,77.7,,1006.22,percent of total billed charges,,,95,,1230.25,percent of total billed charges,,,60,,777,percent of total billed charges,,777,1230.25,
RELIEVA SINUS GUIDE CATHETER,101215,CDM,278,RC,C1887,HCPCS,,,Inpatient,,,1295,,,,80,,1036,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1006.22,percent of total billed charges,,,95,,1230.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1230.25,
RELIEVA SINUS BALLOON CATHETER,101216,CDM,278,RC,C1726,HCPCS,,,Outpatient,,,2733.5,,,,80,,2186.8,percent of total billed charges,,,,85,2323.48,percent of total billed charges,,,77.7,,2123.93,percent of total billed charges,,,95,,2596.83,percent of total billed charges,,,60,,1640.1,percent of total billed charges,,1640.1,2596.83,
RELIEVA SINUS BALLOON CATHETER,101216,CDM,278,RC,C1726,HCPCS,,,Inpatient,,,2733.5,,,,80,,2186.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2123.93,percent of total billed charges,,,95,,2596.83,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2596.83,
RELIEVA SINUS ILLUMINATION SYSTEM,101217,CDM,270,RC,,,,,Outpatient,,,1501.5,,,,80,,1201.2,percent of total billed charges,,,,85,1276.28,percent of total billed charges,,,77.7,,1166.67,percent of total billed charges,,,95,,1426.43,percent of total billed charges,,,60,,900.9,percent of total billed charges,,900.9,1426.43,
RELIEVA SINUS ILLUMINATION SYSTEM,101217,CDM,270,RC,,,,,Inpatient,,,1501.5,,,,80,,1201.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1166.67,percent of total billed charges,,,95,,1426.43,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1426.43,
RELIEVA GUIDE CATHETER HANDLE,101218,CDM,270,RC,,,,,Outpatient,,,192.5,,,,80,,154,percent of total billed charges,,,,85,163.63,percent of total billed charges,,,77.7,,149.57,percent of total billed charges,,,95,,182.88,percent of total billed charges,,,60,,115.5,percent of total billed charges,,115.5,182.88,
RELIEVA GUIDE CATHETER HANDLE,101218,CDM,270,RC,,,,,Inpatient,,,192.5,,,,80,,154,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,149.57,percent of total billed charges,,,95,,182.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,182.88,
RELIEVA SINUS IRRIGATION CATHETER,101219,CDM,270,RC,,,,,Outpatient,,,437.5,,,,80,,350,percent of total billed charges,,,,85,371.88,percent of total billed charges,,,77.7,,339.94,percent of total billed charges,,,95,,415.63,percent of total billed charges,,,60,,262.5,percent of total billed charges,,262.5,415.63,
RELIEVA SINUS IRRIGATION CATHETER,101219,CDM,270,RC,,,,,Inpatient,,,437.5,,,,80,,350,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,339.94,percent of total billed charges,,,95,,415.63,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,415.63,
RELIEVA  SINUS BALLOON INFLATION DEVICE,101220,CDM,278,RC,C1726,HCPCS,,,Outpatient,,,261,,,,80,,208.8,percent of total billed charges,,,,85,221.85,percent of total billed charges,,,77.7,,202.8,percent of total billed charges,,,95,,247.95,percent of total billed charges,,,60,,156.6,percent of total billed charges,,156.6,247.95,
RELIEVA  SINUS BALLOON INFLATION DEVICE,101220,CDM,278,RC,C1726,HCPCS,,,Inpatient,,,261,,,,80,,208.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,202.8,percent of total billed charges,,,95,,247.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,247.95,
MEPILEX BORDER 6 X 8,101221,CDM,270,RC,,,,,Outpatient,,,24.7,,,,80,,19.76,percent of total billed charges,,,,85,21,percent of total billed charges,,,77.7,,19.19,percent of total billed charges,,,95,,23.47,percent of total billed charges,,,60,,14.82,percent of total billed charges,,14.82,23.47,
MEPILEX BORDER 6 X 8,101221,CDM,270,RC,,,,,Inpatient,,,24.7,,,,80,,19.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.19,percent of total billed charges,,,95,,23.47,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,23.47,
DISPERSIVE GROUND INFANT/ADULT >11#,101222,CDM,270,RC,,,,,Outpatient,,,5.2,,,,80,,4.16,percent of total billed charges,,,,85,4.42,percent of total billed charges,,,77.7,,4.04,percent of total billed charges,,,95,,4.94,percent of total billed charges,,,60,,3.12,percent of total billed charges,,3.12,4.94,
DISPERSIVE GROUND INFANT/ADULT >11#,101222,CDM,270,RC,,,,,Inpatient,,,5.2,,,,80,,4.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.04,percent of total billed charges,,,95,,4.94,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.94,
SKINTEGRITY HYDROGEL,101224,CDM,270,RC,,,,,Outpatient,,,18.4,,,,80,,14.72,percent of total billed charges,,,,85,15.64,percent of total billed charges,,,77.7,,14.3,percent of total billed charges,,,95,,17.48,percent of total billed charges,,,60,,11.04,percent of total billed charges,,11.04,17.48,
SKINTEGRITY HYDROGEL,101224,CDM,270,RC,,,,,Inpatient,,,18.4,,,,80,,14.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.3,percent of total billed charges,,,95,,17.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.48,
INTRAOSSEOUS NEEDLE 15G 25MM EZ-IO ADULT,101226,CDM,270,RC,,,,,Outpatient,,,199.7,,,,80,,159.76,percent of total billed charges,,,,85,169.75,percent of total billed charges,,,77.7,,155.17,percent of total billed charges,,,95,,189.72,percent of total billed charges,,,60,,119.82,percent of total billed charges,,119.82,189.72,
INTRAOSSEOUS NEEDLE 15G 25MM EZ-IO ADULT,101226,CDM,270,RC,,,,,Inpatient,,,199.7,,,,80,,159.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,155.17,percent of total billed charges,,,95,,189.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,189.72,
INTRAOSSEOUS NEEDLE 15G 15MM EZ-IO PED,101227,CDM,270,RC,,,,,Outpatient,,,45.8,,,,80,,36.64,percent of total billed charges,,,,85,38.93,percent of total billed charges,,,77.7,,35.59,percent of total billed charges,,,95,,43.51,percent of total billed charges,,,60,,27.48,percent of total billed charges,,27.48,43.51,
INTRAOSSEOUS NEEDLE 15G 15MM EZ-IO PED,101227,CDM,270,RC,,,,,Inpatient,,,45.8,,,,80,,36.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,35.59,percent of total billed charges,,,95,,43.51,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,43.51,
INTRAOSSEOUS NEEDLE 15G 45MM EZ-IO,101228,CDM,270,RC,,,,,Outpatient,,,296,,,,80,,236.8,percent of total billed charges,,,,85,251.6,percent of total billed charges,,,77.7,,229.99,percent of total billed charges,,,95,,281.2,percent of total billed charges,,,60,,177.6,percent of total billed charges,,177.6,281.2,
INTRAOSSEOUS NEEDLE 15G 45MM EZ-IO,101228,CDM,270,RC,,,,,Inpatient,,,296,,,,80,,236.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,229.99,percent of total billed charges,,,95,,281.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,281.2,
CARTER-THOMASON CLOSESURE SYSTEM,101229,CDM,270,RC,,,,,Outpatient,,,510.3,,,,80,,408.24,percent of total billed charges,,,,85,433.76,percent of total billed charges,,,77.7,,396.5,percent of total billed charges,,,95,,484.79,percent of total billed charges,,,60,,306.18,percent of total billed charges,,306.18,484.79,
CARTER-THOMASON CLOSESURE SYSTEM,101229,CDM,270,RC,,,,,Inpatient,,,510.3,,,,80,,408.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,396.5,percent of total billed charges,,,95,,484.79,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,484.79,
VAC CANISTER NO GEL,101230,CDM,270,RC,,,,,Outpatient,,,108.3,,,,80,,86.64,percent of total billed charges,,,,85,92.06,percent of total billed charges,,,77.7,,84.15,percent of total billed charges,,,95,,102.89,percent of total billed charges,,,60,,64.98,percent of total billed charges,,64.98,102.89,
VAC CANISTER NO GEL,101230,CDM,270,RC,,,,,Inpatient,,,108.3,,,,80,,86.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,84.15,percent of total billed charges,,,95,,102.89,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,102.89,
SUCTION IRRIGATOR BARD,101233,CDM,270,RC,,,,,Outpatient,,,187,,,,80,,149.6,percent of total billed charges,,,,85,158.95,percent of total billed charges,,,77.7,,145.3,percent of total billed charges,,,95,,177.65,percent of total billed charges,,,60,,112.2,percent of total billed charges,,112.2,177.65,
SUCTION IRRIGATOR BARD,101233,CDM,270,RC,,,,,Inpatient,,,187,,,,80,,149.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,145.3,percent of total billed charges,,,95,,177.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,177.65,
ENDO GRASPER ETHICON,101234,CDM,270,RC,,,,,Outpatient,,,266.8,,,,80,,213.44,percent of total billed charges,,,,85,226.78,percent of total billed charges,,,77.7,,207.3,percent of total billed charges,,,95,,253.46,percent of total billed charges,,,60,,160.08,percent of total billed charges,,160.08,253.46,
ENDO GRASPER ETHICON,101234,CDM,270,RC,,,,,Inpatient,,,266.8,,,,80,,213.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,207.3,percent of total billed charges,,,95,,253.46,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,253.46,
DRAIN SILICONE ROUND 19FR,101235,CDM,270,RC,,,,,Outpatient,,,22.6,,,,80,,18.08,percent of total billed charges,,,,85,19.21,percent of total billed charges,,,77.7,,17.56,percent of total billed charges,,,95,,21.47,percent of total billed charges,,,60,,13.56,percent of total billed charges,,13.56,21.47,
DRAIN SILICONE ROUND 19FR,101235,CDM,270,RC,,,,,Inpatient,,,22.6,,,,80,,18.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,17.56,percent of total billed charges,,,95,,21.47,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,21.47,
ENDO AVITENE DAVOL,101236,CDM,270,RC,,,,,Outpatient,,,49.5,,,,80,,39.6,percent of total billed charges,,,,85,42.08,percent of total billed charges,,,77.7,,38.46,percent of total billed charges,,,95,,47.03,percent of total billed charges,,,60,,29.7,percent of total billed charges,,29.7,47.03,
ENDO AVITENE DAVOL,101236,CDM,270,RC,,,,,Inpatient,,,49.5,,,,80,,39.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,38.46,percent of total billed charges,,,95,,47.03,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,47.03,
NIPPLE SHIELD MED NON STERILE,101239,CDM,270,RC,,,,,Outpatient,,,13.9,,,,80,,11.12,percent of total billed charges,,,,85,11.82,percent of total billed charges,,,77.7,,10.8,percent of total billed charges,,,95,,13.21,percent of total billed charges,,,60,,8.34,percent of total billed charges,,8.34,13.21,
NIPPLE SHIELD MED NON STERILE,101239,CDM,270,RC,,,,,Inpatient,,,13.9,,,,80,,11.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.8,percent of total billed charges,,,95,,13.21,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.21,
WALKER SPLINT LARGE LEFT,101240,CDM,274,RC,L1830,HCPCS,,,Outpatient,,,100.5,,,,80,,80.4,percent of total billed charges,,,,85,85.43,percent of total billed charges,,,77.7,,78.09,percent of total billed charges,,,95,,95.48,percent of total billed charges,,,60,,60.3,percent of total billed charges,,60.3,95.48,
WALKER SPLINT LARGE LEFT,101240,CDM,274,RC,L1830,HCPCS,,,Inpatient,,,100.5,,,,80,,80.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,78.09,percent of total billed charges,,,95,,95.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,95.48,
WALKER CUFF,101241,CDM,274,RC,L1830,HCPCS,,,Outpatient,,,67,,,,80,,53.6,percent of total billed charges,,,,85,56.95,percent of total billed charges,,,77.7,,52.06,percent of total billed charges,,,95,,63.65,percent of total billed charges,,,60,,40.2,percent of total billed charges,,40.2,63.65,
WALKER CUFF,101241,CDM,274,RC,L1830,HCPCS,,,Inpatient,,,67,,,,80,,53.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,52.06,percent of total billed charges,,,95,,63.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,63.65,
IRRIGATION  WATER 100 ML BTL KENDALL,101242,CDM,270,RC,,,,,Outpatient,,,2.1,,,,80,,1.68,percent of total billed charges,,,,85,1.79,percent of total billed charges,,,77.7,,1.63,percent of total billed charges,,,95,,2,percent of total billed charges,,,60,,1.26,percent of total billed charges,,1.26,2,
IRRIGATION  WATER 100 ML BTL KENDALL,101242,CDM,270,RC,,,,,Inpatient,,,2.1,,,,80,,1.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.63,percent of total billed charges,,,95,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2,
IRRIGATION SALINE 100 ML BTL KENDALL,101243,CDM,270,RC,,,,,Outpatient,,,2.3,,,,80,,1.84,percent of total billed charges,,,,85,1.96,percent of total billed charges,,,77.7,,1.79,percent of total billed charges,,,95,,2.19,percent of total billed charges,,,60,,1.38,percent of total billed charges,,1.38,2.19,
IRRIGATION SALINE 100 ML BTL KENDALL,101243,CDM,270,RC,,,,,Inpatient,,,2.3,,,,80,,1.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.79,percent of total billed charges,,,95,,2.19,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.19,
FLEXIGEL 4X4 DRESSING,101245,CDM,270,RC,,,,,Outpatient,,,12.5,,,,80,,10,percent of total billed charges,,,,85,10.63,percent of total billed charges,,,77.7,,9.71,percent of total billed charges,,,95,,11.88,percent of total billed charges,,,60,,7.5,percent of total billed charges,,7.5,11.88,
FLEXIGEL 4X4 DRESSING,101245,CDM,270,RC,,,,,Inpatient,,,12.5,,,,80,,10,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.71,percent of total billed charges,,,95,,11.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.88,
AUTO TRAK NASAL M/L W/HEADBAND,101249,CDM,270,RC,,,,,Outpatient,,,44.6,,,,80,,35.68,percent of total billed charges,,,,85,37.91,percent of total billed charges,,,77.7,,34.65,percent of total billed charges,,,95,,42.37,percent of total billed charges,,,60,,26.76,percent of total billed charges,,26.76,42.37,
AUTO TRAK NASAL M/L W/HEADBAND,101249,CDM,270,RC,,,,,Inpatient,,,44.6,,,,80,,35.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,34.65,percent of total billed charges,,,95,,42.37,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,42.37,
AVITENE ULTRAFOAM COLLAGEN SPONGE,101250,CDM,270,RC,,,,,Outpatient,,,76.3,,,,80,,61.04,percent of total billed charges,,,,85,64.86,percent of total billed charges,,,77.7,,59.29,percent of total billed charges,,,95,,72.49,percent of total billed charges,,,60,,45.78,percent of total billed charges,,45.78,72.49,
AVITENE ULTRAFOAM COLLAGEN SPONGE,101250,CDM,270,RC,,,,,Inpatient,,,76.3,,,,80,,61.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,59.29,percent of total billed charges,,,95,,72.49,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,72.49,
STUMP COVER XLG,101295,CDM,270,RC,,,,,Outpatient,,,119,,,,80,,95.2,percent of total billed charges,,,,85,101.15,percent of total billed charges,,,77.7,,92.46,percent of total billed charges,,,95,,113.05,percent of total billed charges,,,60,,71.4,percent of total billed charges,,71.4,113.05,
STUMP COVER XLG,101295,CDM,270,RC,,,,,Inpatient,,,119,,,,80,,95.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,92.46,percent of total billed charges,,,95,,113.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,113.05,
SCD SLEEVE KNEE HIGH LARGE,101302,CDM,270,RC,,,,,Outpatient,,,31.5,,,,80,,25.2,percent of total billed charges,,,,85,26.78,percent of total billed charges,,,77.7,,24.48,percent of total billed charges,,,95,,29.93,percent of total billed charges,,,60,,18.9,percent of total billed charges,,18.9,29.93,
SCD SLEEVE KNEE HIGH LARGE,101302,CDM,270,RC,,,,,Inpatient,,,31.5,,,,80,,25.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,24.48,percent of total billed charges,,,95,,29.93,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,29.93,
VAC SILVER MED DRESSING,101304,CDM,270,RC,,,,,Outpatient,,,217.1,,,,80,,173.68,percent of total billed charges,,,,85,184.54,percent of total billed charges,,,77.7,,168.69,percent of total billed charges,,,95,,206.25,percent of total billed charges,,,60,,130.26,percent of total billed charges,,130.26,206.25,
VAC SILVER MED DRESSING,101304,CDM,270,RC,,,,,Inpatient,,,217.1,,,,80,,173.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,168.69,percent of total billed charges,,,95,,206.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,206.25,
VAC SIMPLACE SMALL DRESSING,101305,CDM,270,RC,,,,,Outpatient,,,142.5,,,,80,,114,percent of total billed charges,,,,85,121.13,percent of total billed charges,,,77.7,,110.72,percent of total billed charges,,,95,,135.38,percent of total billed charges,,,60,,85.5,percent of total billed charges,,85.5,135.38,
VAC SIMPLACE SMALL DRESSING,101305,CDM,270,RC,,,,,Inpatient,,,142.5,,,,80,,114,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,110.72,percent of total billed charges,,,95,,135.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,135.38,
STATLOCK KIT,101307,CDM,270,RC,,,,,Outpatient,,,3.1,,,,80,,2.48,percent of total billed charges,,,,85,2.64,percent of total billed charges,,,77.7,,2.41,percent of total billed charges,,,95,,2.95,percent of total billed charges,,,60,,1.86,percent of total billed charges,,1.86,2.95,
STATLOCK KIT,101307,CDM,270,RC,,,,,Inpatient,,,3.1,,,,80,,2.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.41,percent of total billed charges,,,95,,2.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.95,
OSTOMY LUBRICATING DEODORANT HOLLISTER,101310,CDM,270,RC,,,,,Outpatient,,,1.1,,,,80,,0.88,percent of total billed charges,,,,85,0.94,percent of total billed charges,,,77.7,,0.85,percent of total billed charges,,,95,,1.05,percent of total billed charges,,,60,,0.66,percent of total billed charges,,0.66,1.05,
OSTOMY LUBRICATING DEODORANT HOLLISTER,101310,CDM,270,RC,,,,,Inpatient,,,1.1,,,,80,,0.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.85,percent of total billed charges,,,95,,1.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.05,
OSTOMY PASTE 2 OZ,101312,CDM,270,RC,,,,,Outpatient,,,13.9,,,,80,,11.12,percent of total billed charges,,,,85,11.82,percent of total billed charges,,,77.7,,10.8,percent of total billed charges,,,95,,13.21,percent of total billed charges,,,60,,8.34,percent of total billed charges,,8.34,13.21,
OSTOMY PASTE 2 OZ,101312,CDM,270,RC,,,,,Inpatient,,,13.9,,,,80,,11.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.8,percent of total billed charges,,,95,,13.21,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.21,
ADAPTIC DRESSING 3X3,101313,CDM,270,RC,,,,,Outpatient,,,1,,,,80,,0.8,percent of total billed charges,,,,85,0.85,percent of total billed charges,,,77.7,,0.78,percent of total billed charges,,,95,,0.95,percent of total billed charges,,,60,,0.6,percent of total billed charges,,0.6,0.95,
ADAPTIC DRESSING 3X3,101313,CDM,270,RC,,,,,Inpatient,,,1,,,,80,,0.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.78,percent of total billed charges,,,95,,0.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,0.95,
BELLY BAND 12 IN,101314,CDM,270,RC,,,,,Outpatient,,,3.5,,,,80,,2.8,percent of total billed charges,,,,85,2.98,percent of total billed charges,,,77.7,,2.72,percent of total billed charges,,,95,,3.33,percent of total billed charges,,,60,,2.1,percent of total billed charges,,2.1,3.33,
BELLY BAND 12 IN,101314,CDM,270,RC,,,,,Inpatient,,,3.5,,,,80,,2.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.72,percent of total billed charges,,,95,,3.33,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.33,
SPLASHCAP WOUND IRRIG SHIELD,101316,CDM,270,RC,,,,,Outpatient,,,10.7,,,,80,,8.56,percent of total billed charges,,,,85,9.1,percent of total billed charges,,,77.7,,8.31,percent of total billed charges,,,95,,10.17,percent of total billed charges,,,60,,6.42,percent of total billed charges,,6.42,10.17,
SPLASHCAP WOUND IRRIG SHIELD,101316,CDM,270,RC,,,,,Inpatient,,,10.7,,,,80,,8.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.31,percent of total billed charges,,,95,,10.17,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.17,
BLADDER CONTROL PADS,101317,CDM,270,RC,,,,,Outpatient,,,10.4,,,,80,,8.32,percent of total billed charges,,,,85,8.84,percent of total billed charges,,,77.7,,8.08,percent of total billed charges,,,95,,9.88,percent of total billed charges,,,60,,6.24,percent of total billed charges,,6.24,9.88,
BLADDER CONTROL PADS,101317,CDM,270,RC,,,,,Inpatient,,,10.4,,,,80,,8.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.08,percent of total billed charges,,,95,,9.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.88,
LINEAR CUTTER ETS FLEX 45 ETH,101319,CDM,270,RC,,,,,Outpatient,,,501.2,,,,80,,400.96,percent of total billed charges,,,,85,426.02,percent of total billed charges,,,77.7,,389.43,percent of total billed charges,,,95,,476.14,percent of total billed charges,,,60,,300.72,percent of total billed charges,,300.72,476.14,
LINEAR CUTTER ETS FLEX 45 ETH,101319,CDM,270,RC,,,,,Inpatient,,,501.2,,,,80,,400.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,389.43,percent of total billed charges,,,95,,476.14,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,476.14,
LINEAR STAPLER RELOAD ETS FLEX 45 WHITE,101320,CDM,270,RC,,,,,Outpatient,,,414.3,,,,80,,331.44,percent of total billed charges,,,,85,352.16,percent of total billed charges,,,77.7,,321.91,percent of total billed charges,,,95,,393.59,percent of total billed charges,,,60,,248.58,percent of total billed charges,,248.58,393.59,
LINEAR STAPLER RELOAD ETS FLEX 45 WHITE,101320,CDM,270,RC,,,,,Inpatient,,,414.3,,,,80,,331.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,321.91,percent of total billed charges,,,95,,393.59,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,393.59,
VERRES NEEDLE 15CM 14G,101321,CDM,270,RC,,,,,Outpatient,,,44.1,,,,80,,35.28,percent of total billed charges,,,,85,37.49,percent of total billed charges,,,77.7,,34.27,percent of total billed charges,,,95,,41.9,percent of total billed charges,,,60,,26.46,percent of total billed charges,,26.46,41.9,
VERRES NEEDLE 15CM 14G,101321,CDM,270,RC,,,,,Inpatient,,,44.1,,,,80,,35.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,34.27,percent of total billed charges,,,95,,41.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,41.9,
SHILEY TRACH 6MM INNER CANNULA,101325,CDM,270,RC,,,,,Outpatient,,,14,,,,80,,11.2,percent of total billed charges,,,,85,11.9,percent of total billed charges,,,77.7,,10.88,percent of total billed charges,,,95,,13.3,percent of total billed charges,,,60,,8.4,percent of total billed charges,,8.4,13.3,
SHILEY TRACH 6MM INNER CANNULA,101325,CDM,270,RC,,,,,Inpatient,,,14,,,,80,,11.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.88,percent of total billed charges,,,95,,13.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.3,
ARM BOARD BENDABLE NEONATE,101328,CDM,270,RC,,,,,Outpatient,,,6.3,,,,80,,5.04,percent of total billed charges,,,,85,5.36,percent of total billed charges,,,77.7,,4.9,percent of total billed charges,,,95,,5.99,percent of total billed charges,,,60,,3.78,percent of total billed charges,,3.78,5.99,
ARM BOARD BENDABLE NEONATE,101328,CDM,270,RC,,,,,Inpatient,,,6.3,,,,80,,5.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.9,percent of total billed charges,,,95,,5.99,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.99,
ANKLE FOOT ORTHOSIS,101330,CDM,274,RC,L2116,HCPCS,,,Outpatient,,,124.1,,,,80,,99.28,percent of total billed charges,,,,50,345.85,fee schedule,,,77.7,,96.43,percent of total billed charges,,,95,,117.9,percent of total billed charges,,,60,,74.46,percent of total billed charges,,74.46,345.85,
ANKLE FOOT ORTHOSIS,101330,CDM,274,RC,L2116,HCPCS,,,Inpatient,,,124.1,,,,80,,99.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,96.43,percent of total billed charges,,,95,,117.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,117.9,
SILVASORB HYDROGEL DRESSING,101331,CDM,270,RC,,,,,Outpatient,,,75.3,,,,80,,60.24,percent of total billed charges,,,,85,64.01,percent of total billed charges,,,77.7,,58.51,percent of total billed charges,,,95,,71.54,percent of total billed charges,,,60,,45.18,percent of total billed charges,,45.18,71.54,
SILVASORB HYDROGEL DRESSING,101331,CDM,270,RC,,,,,Inpatient,,,75.3,,,,80,,60.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,58.51,percent of total billed charges,,,95,,71.54,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,71.54,
HEAD SUPPORT LG SHEA FOAM,101333,CDM,270,RC,,,,,Outpatient,,,14.8,,,,80,,11.84,percent of total billed charges,,,,85,12.58,percent of total billed charges,,,77.7,,11.5,percent of total billed charges,,,95,,14.06,percent of total billed charges,,,60,,8.88,percent of total billed charges,,8.88,14.06,
HEAD SUPPORT LG SHEA FOAM,101333,CDM,270,RC,,,,,Inpatient,,,14.8,,,,80,,11.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.5,percent of total billed charges,,,95,,14.06,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,14.06,
BELLY BAND 14 IN,101334,CDM,270,RC,,,,,Outpatient,,,3.6,,,,80,,2.88,percent of total billed charges,,,,85,3.06,percent of total billed charges,,,77.7,,2.8,percent of total billed charges,,,95,,3.42,percent of total billed charges,,,60,,2.16,percent of total billed charges,,2.16,3.42,
BELLY BAND 14 IN,101334,CDM,270,RC,,,,,Inpatient,,,3.6,,,,80,,2.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.8,percent of total billed charges,,,95,,3.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.42,
BELLY BAND 16 IN,101335,CDM,270,RC,,,,,Outpatient,,,3.8,,,,80,,3.04,percent of total billed charges,,,,85,3.23,percent of total billed charges,,,77.7,,2.95,percent of total billed charges,,,95,,3.61,percent of total billed charges,,,60,,2.28,percent of total billed charges,,2.28,3.61,
BELLY BAND 16 IN,101335,CDM,270,RC,,,,,Inpatient,,,3.8,,,,80,,3.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.95,percent of total billed charges,,,95,,3.61,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.61,
EPIDURAL TUBING HOSPIRA BACK UP ONLY,101337,CDM,270,RC,,,,,Outpatient,,,72.9,,,,80,,58.32,percent of total billed charges,,,,85,61.97,percent of total billed charges,,,77.7,,56.64,percent of total billed charges,,,95,,69.26,percent of total billed charges,,,60,,43.74,percent of total billed charges,,43.74,69.26,
EPIDURAL TUBING HOSPIRA BACK UP ONLY,101337,CDM,270,RC,,,,,Inpatient,,,72.9,,,,80,,58.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,56.64,percent of total billed charges,,,95,,69.26,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,69.26,
ALLEVYN 2X2 THIN DRESSING,101339,CDM,270,RC,,,,,Outpatient,,,4.4,,,,80,,3.52,percent of total billed charges,,,,85,3.74,percent of total billed charges,,,77.7,,3.42,percent of total billed charges,,,95,,4.18,percent of total billed charges,,,60,,2.64,percent of total billed charges,,2.64,4.18,
ALLEVYN 2X2 THIN DRESSING,101339,CDM,270,RC,,,,,Inpatient,,,4.4,,,,80,,3.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.42,percent of total billed charges,,,95,,4.18,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.18,
VAC CANISTER W/GEL FREEDOM,101341,CDM,270,RC,,,,,Outpatient,,,129.7,,,,80,,103.76,percent of total billed charges,,,,85,110.25,percent of total billed charges,,,77.7,,100.78,percent of total billed charges,,,95,,123.22,percent of total billed charges,,,60,,77.82,percent of total billed charges,,77.82,123.22,
VAC CANISTER W/GEL FREEDOM,101341,CDM,270,RC,,,,,Inpatient,,,129.7,,,,80,,103.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,100.78,percent of total billed charges,,,95,,123.22,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,123.22,
CLAVE T WITH SPIN COLLAR,101342,CDM,270,RC,,,,,Outpatient,,,16.5,,,,80,,13.2,percent of total billed charges,,,,85,14.03,percent of total billed charges,,,77.7,,12.82,percent of total billed charges,,,95,,15.68,percent of total billed charges,,,60,,9.9,percent of total billed charges,,9.9,15.68,
CLAVE T WITH SPIN COLLAR,101342,CDM,270,RC,,,,,Inpatient,,,16.5,,,,80,,13.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.82,percent of total billed charges,,,95,,15.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.68,
EZ STABILIZER IO,101347,CDM,270,RC,,,,,Outpatient,,,37.1,,,,80,,29.68,percent of total billed charges,,,,85,31.54,percent of total billed charges,,,77.7,,28.83,percent of total billed charges,,,95,,35.25,percent of total billed charges,,,60,,22.26,percent of total billed charges,,22.26,35.25,
EZ STABILIZER IO,101347,CDM,270,RC,,,,,Inpatient,,,37.1,,,,80,,29.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,28.83,percent of total billed charges,,,95,,35.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,35.25,
PERFORMAX SPU LARGE,101348,CDM,270,RC,,,,,Outpatient,,,155.4,,,,80,,124.32,percent of total billed charges,,,,85,132.09,percent of total billed charges,,,77.7,,120.75,percent of total billed charges,,,95,,147.63,percent of total billed charges,,,60,,93.24,percent of total billed charges,,93.24,147.63,
PERFORMAX SPU LARGE,101348,CDM,270,RC,,,,,Inpatient,,,155.4,,,,80,,124.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,120.75,percent of total billed charges,,,95,,147.63,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,147.63,
PERFORMAX SPU XLARGE,101349,CDM,270,RC,,,,,Outpatient,,,222.8,,,,80,,178.24,percent of total billed charges,,,,85,189.38,percent of total billed charges,,,77.7,,173.12,percent of total billed charges,,,95,,211.66,percent of total billed charges,,,60,,133.68,percent of total billed charges,,133.68,211.66,
PERFORMAX SPU XLARGE,101349,CDM,270,RC,,,,,Inpatient,,,222.8,,,,80,,178.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,173.12,percent of total billed charges,,,95,,211.66,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,211.66,
NEEDLE SPINAL 20 X 2 1/2,101350,CDM,270,RC,,,,,Outpatient,,,8.5,,,,80,,6.8,percent of total billed charges,,,,85,7.23,percent of total billed charges,,,77.7,,6.6,percent of total billed charges,,,95,,8.08,percent of total billed charges,,,60,,5.1,percent of total billed charges,,5.1,8.08,
NEEDLE SPINAL 20 X 2 1/2,101350,CDM,270,RC,,,,,Inpatient,,,8.5,,,,80,,6.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.6,percent of total billed charges,,,95,,8.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,8.08,
RELIEVA SINUS GUIDE CATH FRONTAL,101352,CDM,278,RC,C1887,HCPCS,,,Outpatient,,,1295,,,,80,,1036,percent of total billed charges,,,,85,1100.75,percent of total billed charges,,,77.7,,1006.22,percent of total billed charges,,,95,,1230.25,percent of total billed charges,,,60,,777,percent of total billed charges,,777,1230.25,
RELIEVA SINUS GUIDE CATH FRONTAL,101352,CDM,278,RC,C1887,HCPCS,,,Inpatient,,,1295,,,,80,,1036,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1006.22,percent of total billed charges,,,95,,1230.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1230.25,
COUDE CATHETER - 14 FR 5CC,101358,CDM,270,RC,,,,,Outpatient,,,31.2,,,,80,,24.96,percent of total billed charges,,,,85,26.52,percent of total billed charges,,,77.7,,24.24,percent of total billed charges,,,95,,29.64,percent of total billed charges,,,60,,18.72,percent of total billed charges,,18.72,29.64,
COUDE CATHETER - 14 FR 5CC,101358,CDM,270,RC,,,,,Inpatient,,,31.2,,,,80,,24.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,24.24,percent of total billed charges,,,95,,29.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,29.64,
FOLEY CATH TUBE 24FR 30CC 2 WAY,101360,CDM,270,RC,,,,,Outpatient,,,9.3,,,,80,,7.44,percent of total billed charges,,,,85,7.91,percent of total billed charges,,,77.7,,7.23,percent of total billed charges,,,95,,8.84,percent of total billed charges,,,60,,5.58,percent of total billed charges,,5.58,8.84,
FOLEY CATH TUBE 24FR 30CC 2 WAY,101360,CDM,270,RC,,,,,Inpatient,,,9.3,,,,80,,7.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.23,percent of total billed charges,,,95,,8.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,8.84,
HICKMAN REPAIR LINE,101370,CDM,270,RC,,,,,Outpatient,,,745.4,,,,80,,596.32,percent of total billed charges,,,,85,633.59,percent of total billed charges,,,77.7,,579.18,percent of total billed charges,,,95,,708.13,percent of total billed charges,,,60,,447.24,percent of total billed charges,,447.24,708.13,
HICKMAN REPAIR LINE,101370,CDM,270,RC,,,,,Inpatient,,,745.4,,,,80,,596.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,579.18,percent of total billed charges,,,95,,708.13,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,708.13,
BLOOD SECONDARY LINE,101371,CDM,270,RC,,,,,Outpatient,,,7.9,,,,80,,6.32,percent of total billed charges,,,,85,6.72,percent of total billed charges,,,77.7,,6.14,percent of total billed charges,,,95,,7.51,percent of total billed charges,,,60,,4.74,percent of total billed charges,,4.74,7.51,
BLOOD SECONDARY LINE,101371,CDM,270,RC,,,,,Inpatient,,,7.9,,,,80,,6.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.14,percent of total billed charges,,,95,,7.51,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.51,
UROSTOMY POUCH W/ FLAT BARRIER,101384,CDM,274,RC,A4428,HCPCS,,,Outpatient,,,5,,,,80,,4,percent of total billed charges,,,,50,5.45,fee schedule,,,77.7,,3.89,percent of total billed charges,,,95,,4.75,percent of total billed charges,,,60,,3,percent of total billed charges,,3,5.45,
UROSTOMY POUCH W/ FLAT BARRIER,101384,CDM,274,RC,A4428,HCPCS,,,Inpatient,,,5,,,,80,,4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.89,percent of total billed charges,,,95,,4.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.75,
CURETTE ENDOMETRIAL SUCTION 3MM,101386,CDM,270,RC,,,,,Outpatient,,,24.9,,,,80,,19.92,percent of total billed charges,,,,85,21.17,percent of total billed charges,,,77.7,,19.35,percent of total billed charges,,,95,,23.66,percent of total billed charges,,,60,,14.94,percent of total billed charges,,14.94,23.66,
CURETTE ENDOMETRIAL SUCTION 3MM,101386,CDM,270,RC,,,,,Inpatient,,,24.9,,,,80,,19.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.35,percent of total billed charges,,,95,,23.66,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,23.66,
SOUND FUNDUS XM,101387,CDM,270,RC,,,,,Outpatient,,,13.5,,,,80,,10.8,percent of total billed charges,,,,85,11.48,percent of total billed charges,,,77.7,,10.49,percent of total billed charges,,,95,,12.83,percent of total billed charges,,,60,,8.1,percent of total billed charges,,8.1,12.83,
SOUND FUNDUS XM,101387,CDM,270,RC,,,,,Inpatient,,,13.5,,,,80,,10.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.49,percent of total billed charges,,,95,,12.83,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,12.83,
ENDOSTITCH 10 MM,101388,CDM,270,RC,,,,,Outpatient,,,122,,,,80,,97.6,percent of total billed charges,,,,85,103.7,percent of total billed charges,,,77.7,,94.79,percent of total billed charges,,,95,,115.9,percent of total billed charges,,,60,,73.2,percent of total billed charges,,73.2,115.9,
ENDOSTITCH 10 MM,101388,CDM,270,RC,,,,,Inpatient,,,122,,,,80,,97.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,94.79,percent of total billed charges,,,95,,115.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,115.9,
LIGAMAX 5MM CLIP APPLIER,101390,CDM,270,RC,,,,,Outpatient,,,587.6,,,,80,,470.08,percent of total billed charges,,,,85,499.46,percent of total billed charges,,,77.7,,456.57,percent of total billed charges,,,95,,558.22,percent of total billed charges,,,60,,352.56,percent of total billed charges,,352.56,558.22,
LIGAMAX 5MM CLIP APPLIER,101390,CDM,270,RC,,,,,Inpatient,,,587.6,,,,80,,470.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,456.57,percent of total billed charges,,,95,,558.22,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,558.22,
TROCAR SLEEVE OPTIVIEW XCEL,101391,CDM,270,RC,,,,,Outpatient,,,52.5,,,,80,,42,percent of total billed charges,,,,85,44.63,percent of total billed charges,,,77.7,,40.79,percent of total billed charges,,,95,,49.88,percent of total billed charges,,,60,,31.5,percent of total billed charges,,31.5,49.88,
TROCAR SLEEVE OPTIVIEW XCEL,101391,CDM,270,RC,,,,,Inpatient,,,52.5,,,,80,,42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,40.79,percent of total billed charges,,,95,,49.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,49.88,
ENTELLUS MULTI-SINUS DILATION TOOL,101393,CDM,278,RC,C1726,HCPCS,,,Outpatient,,,3130.8,,,,80,,2504.64,percent of total billed charges,,,,85,2661.18,percent of total billed charges,,,77.7,,2432.63,percent of total billed charges,,,95,,2974.26,percent of total billed charges,,,60,,1878.48,percent of total billed charges,,1878.48,2974.26,
ENTELLUS MULTI-SINUS DILATION TOOL,101393,CDM,278,RC,C1726,HCPCS,,,Inpatient,,,3130.8,,,,80,,2504.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2432.63,percent of total billed charges,,,95,,2974.26,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2974.26,
MEPILEX BORDER 4 X 4,101394,CDM,270,RC,,,,,Outpatient,,,83.4,,,,80,,66.72,percent of total billed charges,,,,85,70.89,percent of total billed charges,,,77.7,,64.8,percent of total billed charges,,,95,,79.23,percent of total billed charges,,,60,,50.04,percent of total billed charges,,50.04,79.23,
MEPILEX BORDER 4 X 4,101394,CDM,270,RC,,,,,Inpatient,,,83.4,,,,80,,66.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,64.8,percent of total billed charges,,,95,,79.23,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,79.23,
PREVENT FLOW SENSOR,101395,CDM,270,RC,,,,,Outpatient,,,59.4,,,,80,,47.52,percent of total billed charges,,,,85,50.49,percent of total billed charges,,,77.7,,46.15,percent of total billed charges,,,95,,56.43,percent of total billed charges,,,60,,35.64,percent of total billed charges,,35.64,56.43,
PREVENT FLOW SENSOR,101395,CDM,270,RC,,,,,Inpatient,,,59.4,,,,80,,47.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,46.15,percent of total billed charges,,,95,,56.43,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,56.43,
MEDIHONEY 2 X 2 DRESSING,101399,CDM,270,RC,,,,,Outpatient,,,14.1,,,,80,,11.28,percent of total billed charges,,,,85,11.99,percent of total billed charges,,,77.7,,10.96,percent of total billed charges,,,95,,13.4,percent of total billed charges,,,60,,8.46,percent of total billed charges,,8.46,13.4,
MEDIHONEY 2 X 2 DRESSING,101399,CDM,270,RC,,,,,Inpatient,,,14.1,,,,80,,11.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.96,percent of total billed charges,,,95,,13.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.4,
DISPERSIVE GROUND INFANT COVIDIEN,101401,CDM,270,RC,,,,,Outpatient,,,1.6,,,,80,,1.28,percent of total billed charges,,,,85,1.36,percent of total billed charges,,,77.7,,1.24,percent of total billed charges,,,95,,1.52,percent of total billed charges,,,60,,0.96,percent of total billed charges,,0.96,1.52,
DISPERSIVE GROUND INFANT COVIDIEN,101401,CDM,270,RC,,,,,Inpatient,,,1.6,,,,80,,1.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.24,percent of total billed charges,,,95,,1.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.52,
PEDICAP CO2 DETECTOR PED,101402,CDM,270,RC,,,,,Outpatient,,,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
PEDICAP CO2 DETECTOR PED,101402,CDM,270,RC,,,,,Inpatient,,,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
HEALING SHOE XSMALL,101403,CDM,274,RC,L3260,HCPCS,,,Outpatient,,,18.3,,,,80,,14.64,percent of total billed charges,,,,85,15.56,percent of total billed charges,,,77.7,,14.22,percent of total billed charges,,,95,,17.39,percent of total billed charges,,,60,,10.98,percent of total billed charges,,10.98,17.39,
HEALING SHOE XSMALL,101403,CDM,274,RC,L3260,HCPCS,,,Inpatient,,,18.3,,,,80,,14.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.22,percent of total billed charges,,,95,,17.39,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.39,
SKIN BARRIER PREP,101406,CDM,270,RC,,,,,Outpatient,,,2,,,,80,,1.6,percent of total billed charges,,,,85,1.7,percent of total billed charges,,,77.7,,1.55,percent of total billed charges,,,95,,1.9,percent of total billed charges,,,60,,1.2,percent of total billed charges,,1.2,1.9,
SKIN BARRIER PREP,101406,CDM,270,RC,,,,,Inpatient,,,2,,,,80,,1.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.55,percent of total billed charges,,,95,,1.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.9,
NEEDLE SPINAL QUINKE 18 X 3 1/2,101415,CDM,270,RC,,,,,Outpatient,,,7.8,,,,80,,6.24,percent of total billed charges,,,,85,6.63,percent of total billed charges,,,77.7,,6.06,percent of total billed charges,,,95,,7.41,percent of total billed charges,,,60,,4.68,percent of total billed charges,,4.68,7.41,
NEEDLE SPINAL QUINKE 18 X 3 1/2,101415,CDM,270,RC,,,,,Inpatient,,,7.8,,,,80,,6.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.06,percent of total billed charges,,,95,,7.41,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.41,
"ELECTRODE  BLADE 1"" ULTRACLEAN",101416,CDM,270,RC,,,,,Outpatient,,,16.8,,,,80,,13.44,percent of total billed charges,,,,85,14.28,percent of total billed charges,,,77.7,,13.05,percent of total billed charges,,,95,,15.96,percent of total billed charges,,,60,,10.08,percent of total billed charges,,10.08,15.96,
"ELECTRODE  BLADE 1"" ULTRACLEAN",101416,CDM,270,RC,,,,,Inpatient,,,16.8,,,,80,,13.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,13.05,percent of total billed charges,,,95,,15.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.96,
CHLORAPREP ORANGE 26 ML,101417,CDM,270,RC,,,,,Outpatient,,,24.2,,,,80,,19.36,percent of total billed charges,,,,85,20.57,percent of total billed charges,,,77.7,,18.8,percent of total billed charges,,,95,,22.99,percent of total billed charges,,,60,,14.52,percent of total billed charges,,14.52,22.99,
CHLORAPREP ORANGE 26 ML,101417,CDM,270,RC,,,,,Inpatient,,,24.2,,,,80,,19.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,18.8,percent of total billed charges,,,95,,22.99,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,22.99,
SCRUB SOLUTION EXIDINE 2% 4 OZ,101418,CDM,270,RC,,,,,Outpatient,,,7.5,,,,80,,6,percent of total billed charges,,,,85,6.38,percent of total billed charges,,,77.7,,5.83,percent of total billed charges,,,95,,7.13,percent of total billed charges,,,60,,4.5,percent of total billed charges,,4.5,7.13,
SCRUB SOLUTION EXIDINE 2% 4 OZ,101418,CDM,270,RC,,,,,Inpatient,,,7.5,,,,80,,6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.83,percent of total billed charges,,,95,,7.13,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.13,
"ZZZESMARK BANDAGE 3"" X 12'",101419,CDM,270,RC,,,,,Outpatient,,,49.6,,,,80,,39.68,percent of total billed charges,,,,85,42.16,percent of total billed charges,,,77.7,,38.54,percent of total billed charges,,,95,,47.12,percent of total billed charges,,,60,,29.76,percent of total billed charges,,29.76,47.12,
"ZZZESMARK BANDAGE 3"" X 12'",101419,CDM,270,RC,,,,,Inpatient,,,49.6,,,,80,,39.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,38.54,percent of total billed charges,,,95,,47.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,47.12,
CUTIMED SORBACT 2.75 X 3.5,101422,CDM,270,RC,,,,,Outpatient,,,17.5,,,,80,,14,percent of total billed charges,,,,85,14.88,percent of total billed charges,,,77.7,,13.6,percent of total billed charges,,,95,,16.63,percent of total billed charges,,,60,,10.5,percent of total billed charges,,10.5,16.63,
CUTIMED SORBACT 2.75 X 3.5,101422,CDM,270,RC,,,,,Inpatient,,,17.5,,,,80,,14,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,13.6,percent of total billed charges,,,95,,16.63,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,16.63,
CUTIMED SORBACT 4 X 4,101423,CDM,270,RC,,,,,Outpatient,,,12.2,,,,80,,9.76,percent of total billed charges,,,,85,10.37,percent of total billed charges,,,77.7,,9.48,percent of total billed charges,,,95,,11.59,percent of total billed charges,,,60,,7.32,percent of total billed charges,,7.32,11.59,
CUTIMED SORBACT 4 X 4,101423,CDM,270,RC,,,,,Inpatient,,,12.2,,,,80,,9.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.48,percent of total billed charges,,,95,,11.59,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.59,
ONE STEP SPLINT 2 X 10,101426,CDM,270,RC,,,,,Outpatient,,,11.9,,,,80,,9.52,percent of total billed charges,,,,85,10.12,percent of total billed charges,,,77.7,,9.25,percent of total billed charges,,,95,,11.31,percent of total billed charges,,,60,,7.14,percent of total billed charges,,7.14,11.31,
ONE STEP SPLINT 2 X 10,101426,CDM,270,RC,,,,,Inpatient,,,11.9,,,,80,,9.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.25,percent of total billed charges,,,95,,11.31,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.31,
IRRIGATION SET 2 BAG SPIKES,101430,CDM,270,RC,,,,,Outpatient,,,44.8,,,,80,,35.84,percent of total billed charges,,,,85,38.08,percent of total billed charges,,,77.7,,34.81,percent of total billed charges,,,95,,42.56,percent of total billed charges,,,60,,26.88,percent of total billed charges,,26.88,42.56,
IRRIGATION SET 2 BAG SPIKES,101430,CDM,270,RC,,,,,Inpatient,,,44.8,,,,80,,35.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,34.81,percent of total billed charges,,,95,,42.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,42.56,
SHAVER BLADE AGG PLUS 4.O MM,101431,CDM,270,RC,,,,,Outpatient,,,196,,,,80,,156.8,percent of total billed charges,,,,85,166.6,percent of total billed charges,,,77.7,,152.29,percent of total billed charges,,,95,,186.2,percent of total billed charges,,,60,,117.6,percent of total billed charges,,117.6,186.2,
SHAVER BLADE AGG PLUS 4.O MM,101431,CDM,270,RC,,,,,Inpatient,,,196,,,,80,,156.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,152.29,percent of total billed charges,,,95,,186.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,186.2,
SHAVER BLADE AGG PLUS 5.O MM,101432,CDM,270,RC,,,,,Outpatient,,,189,,,,80,,151.2,percent of total billed charges,,,,85,160.65,percent of total billed charges,,,77.7,,146.85,percent of total billed charges,,,95,,179.55,percent of total billed charges,,,60,,113.4,percent of total billed charges,,113.4,179.55,
SHAVER BLADE AGG PLUS 5.O MM,101432,CDM,270,RC,,,,,Inpatient,,,189,,,,80,,151.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,146.85,percent of total billed charges,,,95,,179.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,179.55,
CROSSFLOW INFLOW CASSETTE,101433,CDM,270,RC,,,,,Outpatient,,,213.9,,,,80,,171.12,percent of total billed charges,,,,85,181.82,percent of total billed charges,,,77.7,,166.2,percent of total billed charges,,,95,,203.21,percent of total billed charges,,,60,,128.34,percent of total billed charges,,128.34,203.21,
CROSSFLOW INFLOW CASSETTE,101433,CDM,270,RC,,,,,Inpatient,,,213.9,,,,80,,171.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,166.2,percent of total billed charges,,,95,,203.21,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,203.21,
OSTOMY PASTE CONVATEC,101436,CDM,270,RC,,,,,Outpatient,,,19.4,,,,80,,15.52,percent of total billed charges,,,,85,16.49,percent of total billed charges,,,77.7,,15.07,percent of total billed charges,,,95,,18.43,percent of total billed charges,,,60,,11.64,percent of total billed charges,,11.64,18.43,
OSTOMY PASTE CONVATEC,101436,CDM,270,RC,,,,,Inpatient,,,19.4,,,,80,,15.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,15.07,percent of total billed charges,,,95,,18.43,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,18.43,
SKIN MARKER DUAL TIP,101437,CDM,270,RC,,,,,Outpatient,,,4.2,,,,80,,3.36,percent of total billed charges,,,,85,3.57,percent of total billed charges,,,77.7,,3.26,percent of total billed charges,,,95,,3.99,percent of total billed charges,,,60,,2.52,percent of total billed charges,,2.52,3.99,
SKIN MARKER DUAL TIP,101437,CDM,270,RC,,,,,Inpatient,,,4.2,,,,80,,3.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.26,percent of total billed charges,,,95,,3.99,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.99,
KING AIRWAY SIZE 5 W/SUCTION,101438,CDM,270,RC,,,,,Outpatient,,,150.5,,,,80,,120.4,percent of total billed charges,,,,85,127.93,percent of total billed charges,,,77.7,,116.94,percent of total billed charges,,,95,,142.98,percent of total billed charges,,,60,,90.3,percent of total billed charges,,90.3,142.98,
KING AIRWAY SIZE 5 W/SUCTION,101438,CDM,270,RC,,,,,Inpatient,,,150.5,,,,80,,120.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,116.94,percent of total billed charges,,,95,,142.98,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,142.98,
KING AIRWAY SIZE 4 W/SUCTION,101439,CDM,270,RC,,,,,Outpatient,,,158.6,,,,80,,126.88,percent of total billed charges,,,,85,134.81,percent of total billed charges,,,77.7,,123.23,percent of total billed charges,,,95,,150.67,percent of total billed charges,,,60,,95.16,percent of total billed charges,,95.16,150.67,
KING AIRWAY SIZE 4 W/SUCTION,101439,CDM,270,RC,,,,,Inpatient,,,158.6,,,,80,,126.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,123.23,percent of total billed charges,,,95,,150.67,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,150.67,
KING AIRWAY SIZE 3 W/SUCTION,101440,CDM,270,RC,,,,,Outpatient,,,158.6,,,,80,,126.88,percent of total billed charges,,,,85,134.81,percent of total billed charges,,,77.7,,123.23,percent of total billed charges,,,95,,150.67,percent of total billed charges,,,60,,95.16,percent of total billed charges,,95.16,150.67,
KING AIRWAY SIZE 3 W/SUCTION,101440,CDM,270,RC,,,,,Inpatient,,,158.6,,,,80,,126.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,123.23,percent of total billed charges,,,95,,150.67,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,150.67,
KING AIRWAY SIZE 2.0 W/SUCTION,101441,CDM,270,RC,,,,,Outpatient,,,150.5,,,,80,,120.4,percent of total billed charges,,,,85,127.93,percent of total billed charges,,,77.7,,116.94,percent of total billed charges,,,95,,142.98,percent of total billed charges,,,60,,90.3,percent of total billed charges,,90.3,142.98,
KING AIRWAY SIZE 2.0 W/SUCTION,101441,CDM,270,RC,,,,,Inpatient,,,150.5,,,,80,,120.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,116.94,percent of total billed charges,,,95,,142.98,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,142.98,
KING AIRWAY SIZE 2.5 W/SUCTION,101442,CDM,270,RC,,,,,Outpatient,,,158.6,,,,80,,126.88,percent of total billed charges,,,,85,134.81,percent of total billed charges,,,77.7,,123.23,percent of total billed charges,,,95,,150.67,percent of total billed charges,,,60,,95.16,percent of total billed charges,,95.16,150.67,
KING AIRWAY SIZE 2.5 W/SUCTION,101442,CDM,270,RC,,,,,Inpatient,,,158.6,,,,80,,126.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,123.23,percent of total billed charges,,,95,,150.67,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,150.67,
MESH LIGHT PLUG LARGE BARD/DAVOL,101443,CDM,278,RC,C1781,HCPCS,,,Outpatient,,,389.2,,,,80,,311.36,percent of total billed charges,,,,85,330.82,percent of total billed charges,,,77.7,,302.41,percent of total billed charges,,,95,,369.74,percent of total billed charges,,,60,,233.52,percent of total billed charges,,233.52,369.74,
MESH LIGHT PLUG LARGE BARD/DAVOL,101443,CDM,278,RC,C1781,HCPCS,,,Inpatient,,,389.2,,,,80,,311.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,302.41,percent of total billed charges,,,95,,369.74,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,369.74,
KATZ EXTRACTOR RHINO,101444,CDM,270,RC,,,,,Outpatient,,,299.7,,,,80,,239.76,percent of total billed charges,,,,85,254.75,percent of total billed charges,,,77.7,,232.87,percent of total billed charges,,,95,,284.72,percent of total billed charges,,,60,,179.82,percent of total billed charges,,179.82,284.72,
KATZ EXTRACTOR RHINO,101444,CDM,270,RC,,,,,Inpatient,,,299.7,,,,80,,239.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,232.87,percent of total billed charges,,,95,,284.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,284.72,
L3809 WRIST THUMB LG RT SPLINT,101447,CDM,274,RC,L3809,HCPCS,,,Outpatient,,,43.6,,,,80,,34.88,percent of total billed charges,,,,85,37.06,percent of total billed charges,,,77.7,,33.88,percent of total billed charges,,,95,,41.42,percent of total billed charges,,,60,,26.16,percent of total billed charges,,26.16,41.42,
L3809 WRIST THUMB LG RT SPLINT,101447,CDM,274,RC,L3809,HCPCS,,,Inpatient,,,43.6,,,,80,,34.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,33.88,percent of total billed charges,,,95,,41.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,41.42,
WRIST THUMB LG LT SPLINT,101448,CDM,274,RC,L3809,HCPCS,,,Outpatient,,,43.6,,,,80,,34.88,percent of total billed charges,,,,85,37.06,percent of total billed charges,,,77.7,,33.88,percent of total billed charges,,,95,,41.42,percent of total billed charges,,,60,,26.16,percent of total billed charges,,26.16,41.42,
WRIST THUMB LG LT SPLINT,101448,CDM,274,RC,L3809,HCPCS,,,Inpatient,,,43.6,,,,80,,34.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,33.88,percent of total billed charges,,,95,,41.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,41.42,
CALMOSEPTINE OINTMENT 4 OZ,101449,CDM,270,RC,,,,,Outpatient,,,25.5,,,,80,,20.4,percent of total billed charges,,,,85,21.68,percent of total billed charges,,,77.7,,19.81,percent of total billed charges,,,95,,24.23,percent of total billed charges,,,60,,15.3,percent of total billed charges,,15.3,24.23,
CALMOSEPTINE OINTMENT 4 OZ,101449,CDM,270,RC,,,,,Inpatient,,,25.5,,,,80,,20.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.81,percent of total billed charges,,,95,,24.23,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,24.23,
WRIST THUMB MED RT SPLINT,101451,CDM,274,RC,L3809,HCPCS,,,Outpatient,,,43.6,,,,80,,34.88,percent of total billed charges,,,,85,37.06,percent of total billed charges,,,77.7,,33.88,percent of total billed charges,,,95,,41.42,percent of total billed charges,,,60,,26.16,percent of total billed charges,,26.16,41.42,
WRIST THUMB MED RT SPLINT,101451,CDM,274,RC,L3809,HCPCS,,,Inpatient,,,43.6,,,,80,,34.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,33.88,percent of total billed charges,,,95,,41.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,41.42,
WRIST THUMB SM LT SPLINT,101452,CDM,274,RC,L3809,HCPCS,,,Outpatient,,,51.7,,,,80,,41.36,percent of total billed charges,,,,85,43.95,percent of total billed charges,,,77.7,,40.17,percent of total billed charges,,,95,,49.12,percent of total billed charges,,,60,,31.02,percent of total billed charges,,31.02,49.12,
WRIST THUMB SM LT SPLINT,101452,CDM,274,RC,L3809,HCPCS,,,Inpatient,,,51.7,,,,80,,41.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,40.17,percent of total billed charges,,,95,,49.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,49.12,
WRIST THUMB SM RT SPLINT,101453,CDM,274,RC,L3809,HCPCS,,,Outpatient,,,43.6,,,,80,,34.88,percent of total billed charges,,,,85,37.06,percent of total billed charges,,,77.7,,33.88,percent of total billed charges,,,95,,41.42,percent of total billed charges,,,60,,26.16,percent of total billed charges,,26.16,41.42,
WRIST THUMB SM RT SPLINT,101453,CDM,274,RC,L3809,HCPCS,,,Inpatient,,,43.6,,,,80,,34.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,33.88,percent of total billed charges,,,95,,41.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,41.42,
RELIEVA BALLOON SINUPLASTY SYSTEM,101454,CDM,278,RC,C1726,HCPCS,,,Outpatient,,,5862.5,,,,80,,4690,percent of total billed charges,,,,85,4983.13,percent of total billed charges,,,77.7,,4555.16,percent of total billed charges,,,95,,5569.38,percent of total billed charges,,,60,,3517.5,percent of total billed charges,,3517.5,5569.38,
RELIEVA BALLOON SINUPLASTY SYSTEM,101454,CDM,278,RC,C1726,HCPCS,,,Inpatient,,,5862.5,,,,80,,4690,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4555.16,percent of total billed charges,,,95,,5569.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5569.38,
"ESMARK BANDAGE 6"" X 12' LF STERILE",101464,CDM,270,RC,,,,,Outpatient,,,12.7,,,,80,,10.16,percent of total billed charges,,,,85,10.8,percent of total billed charges,,,77.7,,9.87,percent of total billed charges,,,95,,12.07,percent of total billed charges,,,60,,7.62,percent of total billed charges,,7.62,12.07,
"ESMARK BANDAGE 6"" X 12' LF STERILE",101464,CDM,270,RC,,,,,Inpatient,,,12.7,,,,80,,10.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.87,percent of total billed charges,,,95,,12.07,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,12.07,
"STOCKINETTE 9"" STERILE POLY",101467,CDM,270,RC,,,,,Outpatient,,,27,,,,80,,21.6,percent of total billed charges,,,,85,22.95,percent of total billed charges,,,77.7,,20.98,percent of total billed charges,,,95,,25.65,percent of total billed charges,,,60,,16.2,percent of total billed charges,,16.2,25.65,
"STOCKINETTE 9"" STERILE POLY",101467,CDM,270,RC,,,,,Inpatient,,,27,,,,80,,21.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,20.98,percent of total billed charges,,,95,,25.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,25.65,
"ACE BANDAGE 3"" LF STERILE",101470,CDM,270,RC,,,,,Outpatient,,,6,,,,80,,4.8,percent of total billed charges,,,,85,5.1,percent of total billed charges,,,77.7,,4.66,percent of total billed charges,,,95,,5.7,percent of total billed charges,,,60,,3.6,percent of total billed charges,,3.6,5.7,
"ACE BANDAGE 3"" LF STERILE",101470,CDM,270,RC,,,,,Inpatient,,,6,,,,80,,4.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.66,percent of total billed charges,,,95,,5.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.7,
"ACE BANDAGE 6"" LF STERILE",101471,CDM,270,RC,,,,,Outpatient,,,5.8,,,,80,,4.64,percent of total billed charges,,,,85,4.93,percent of total billed charges,,,77.7,,4.51,percent of total billed charges,,,95,,5.51,percent of total billed charges,,,60,,3.48,percent of total billed charges,,3.48,5.51,
"ACE BANDAGE 6"" LF STERILE",101471,CDM,270,RC,,,,,Inpatient,,,5.8,,,,80,,4.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.51,percent of total billed charges,,,95,,5.51,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.51,
NEEDLE SPINAL QUINKE 22 X 5,101472,CDM,270,RC,,,,,Outpatient,,,22.6,,,,80,,18.08,percent of total billed charges,,,,85,19.21,percent of total billed charges,,,77.7,,17.56,percent of total billed charges,,,95,,21.47,percent of total billed charges,,,60,,13.56,percent of total billed charges,,13.56,21.47,
NEEDLE SPINAL QUINKE 22 X 5,101472,CDM,270,RC,,,,,Inpatient,,,22.6,,,,80,,18.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,17.56,percent of total billed charges,,,95,,21.47,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,21.47,
L4387 WALKING BOOT MAXTRAX SMALL,101475,CDM,274,RC,L4387,HCPCS,,,Outpatient,,,104.3,,,,80,,83.44,percent of total billed charges,,,,85,88.66,percent of total billed charges,,,77.7,,81.04,percent of total billed charges,,,95,,99.09,percent of total billed charges,,,60,,62.58,percent of total billed charges,,62.58,99.09,
L4387 WALKING BOOT MAXTRAX SMALL,101475,CDM,274,RC,L4387,HCPCS,,,Inpatient,,,104.3,,,,80,,83.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,81.04,percent of total billed charges,,,95,,99.09,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,99.09,
WALKING BOOT MAXTRAX MEDIUM,101476,CDM,274,RC,L4387,HCPCS,,,Outpatient,,,188.7,,,,80,,150.96,percent of total billed charges,,,,85,160.4,percent of total billed charges,,,77.7,,146.62,percent of total billed charges,,,95,,179.27,percent of total billed charges,,,60,,113.22,percent of total billed charges,,113.22,179.27,
WALKING BOOT MAXTRAX MEDIUM,101476,CDM,274,RC,L4387,HCPCS,,,Inpatient,,,188.7,,,,80,,150.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,146.62,percent of total billed charges,,,95,,179.27,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,179.27,
ZZZMAXTRAX WALKER LARGE,101477,CDM,274,RC,L4837,HCPCS,,,Outpatient,,,241,,,,80,,192.8,percent of total billed charges,,,,85,204.85,percent of total billed charges,,,77.7,,187.26,percent of total billed charges,,,95,,228.95,percent of total billed charges,,,60,,144.6,percent of total billed charges,,144.6,228.95,
ZZZMAXTRAX WALKER LARGE,101477,CDM,274,RC,L4837,HCPCS,,,Inpatient,,,241,,,,80,,192.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,187.26,percent of total billed charges,,,95,,228.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,228.95,
L2116 WALKING BOOT MAXTRAX XLARGE,101478,CDM,274,RC,L2116,HCPCS,,,Outpatient,,,102.2,,,,80,,81.76,percent of total billed charges,,,,50,345.85,fee schedule,,,77.7,,79.41,percent of total billed charges,,,95,,97.09,percent of total billed charges,,,60,,61.32,percent of total billed charges,,61.32,345.85,
L2116 WALKING BOOT MAXTRAX XLARGE,101478,CDM,274,RC,L2116,HCPCS,,,Inpatient,,,102.2,,,,80,,81.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,79.41,percent of total billed charges,,,95,,97.09,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,97.09,
MAXTRAX WALKER XSMALL,101479,CDM,274,RC,L4837,HCPCS,,,Outpatient,,,92.6,,,,80,,74.08,percent of total billed charges,,,,85,78.71,percent of total billed charges,,,77.7,,71.95,percent of total billed charges,,,95,,87.97,percent of total billed charges,,,60,,55.56,percent of total billed charges,,55.56,87.97,
MAXTRAX WALKER XSMALL,101479,CDM,274,RC,L4837,HCPCS,,,Inpatient,,,92.6,,,,80,,74.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,71.95,percent of total billed charges,,,95,,87.97,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,87.97,
SNARE SENSATION,101480,CDM,270,RC,,,,,Outpatient,,,34.3,,,,80,,27.44,percent of total billed charges,,,,85,29.16,percent of total billed charges,,,77.7,,26.65,percent of total billed charges,,,95,,32.59,percent of total billed charges,,,60,,20.58,percent of total billed charges,,20.58,32.59,
SNARE SENSATION,101480,CDM,270,RC,,,,,Inpatient,,,34.3,,,,80,,27.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,26.65,percent of total billed charges,,,95,,32.59,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,32.59,
SNARE HEXAGONAL,101481,CDM,270,RC,,,,,Outpatient,,,46.1,,,,80,,36.88,percent of total billed charges,,,,85,39.19,percent of total billed charges,,,77.7,,35.82,percent of total billed charges,,,95,,43.8,percent of total billed charges,,,60,,27.66,percent of total billed charges,,27.66,43.8,
SNARE HEXAGONAL,101481,CDM,270,RC,,,,,Inpatient,,,46.1,,,,80,,36.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,35.82,percent of total billed charges,,,95,,43.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,43.8,
BIOPSY FORCEPS HOT RAD JAW 4,101482,CDM,270,RC,,,,,Outpatient,,,165.5,,,,80,,132.4,percent of total billed charges,,,,85,140.68,percent of total billed charges,,,77.7,,128.59,percent of total billed charges,,,95,,157.23,percent of total billed charges,,,60,,99.3,percent of total billed charges,,99.3,157.23,
BIOPSY FORCEPS HOT RAD JAW 4,101482,CDM,270,RC,,,,,Inpatient,,,165.5,,,,80,,132.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,128.59,percent of total billed charges,,,95,,157.23,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,157.23,
BIOPSY FORCEPS COLD RAD JAW 4,101483,CDM,270,RC,,,,,Outpatient,,,69.2,,,,80,,55.36,percent of total billed charges,,,,85,58.82,percent of total billed charges,,,77.7,,53.77,percent of total billed charges,,,95,,65.74,percent of total billed charges,,,60,,41.52,percent of total billed charges,,41.52,65.74,
BIOPSY FORCEPS COLD RAD JAW 4,101483,CDM,270,RC,,,,,Inpatient,,,69.2,,,,80,,55.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,53.77,percent of total billed charges,,,95,,65.74,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,65.74,
INTERJECT INJECTION NEEDLE CATHETER,101484,CDM,270,RC,,,,,Outpatient,,,133.2,,,,80,,106.56,percent of total billed charges,,,,85,113.22,percent of total billed charges,,,77.7,,103.5,percent of total billed charges,,,95,,126.54,percent of total billed charges,,,60,,79.92,percent of total billed charges,,79.92,126.54,
INTERJECT INJECTION NEEDLE CATHETER,101484,CDM,270,RC,,,,,Inpatient,,,133.2,,,,80,,106.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,103.5,percent of total billed charges,,,95,,126.54,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,126.54,
TWISTER PLUS RETRIEVAL DEVICE,101485,CDM,270,RC,,,,,Outpatient,,,303.5,,,,80,,242.8,percent of total billed charges,,,,85,257.98,percent of total billed charges,,,77.7,,235.82,percent of total billed charges,,,95,,288.33,percent of total billed charges,,,60,,182.1,percent of total billed charges,,182.1,288.33,
TWISTER PLUS RETRIEVAL DEVICE,101485,CDM,270,RC,,,,,Inpatient,,,303.5,,,,80,,242.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,235.82,percent of total billed charges,,,95,,288.33,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,288.33,
RESOLUTION CLIP,101486,CDM,270,RC,,,,,Outpatient,,,577.5,,,,80,,462,percent of total billed charges,,,,85,490.88,percent of total billed charges,,,77.7,,448.72,percent of total billed charges,,,95,,548.63,percent of total billed charges,,,60,,346.5,percent of total billed charges,,346.5,548.63,
RESOLUTION CLIP,101486,CDM,270,RC,,,,,Inpatient,,,577.5,,,,80,,462,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,448.72,percent of total billed charges,,,95,,548.63,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,548.63,
BALLOON DILATORS CRE 12-13.5-15MM,101487,CDM,278,RC,C1726,HCPCS,,,Outpatient,,,752.5,,,,80,,602,percent of total billed charges,,,,85,639.63,percent of total billed charges,,,77.7,,584.69,percent of total billed charges,,,95,,714.88,percent of total billed charges,,,60,,451.5,percent of total billed charges,,451.5,714.88,
BALLOON DILATORS CRE 12-13.5-15MM,101487,CDM,278,RC,C1726,HCPCS,,,Inpatient,,,752.5,,,,80,,602,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,584.69,percent of total billed charges,,,95,,714.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,714.88,
BALLOON DILATORS CRE 15-16.6-18MM,101488,CDM,278,RC,C1726,HCPCS,,,Outpatient,,,768,,,,80,,614.4,percent of total billed charges,,,,85,652.8,percent of total billed charges,,,77.7,,596.74,percent of total billed charges,,,95,,729.6,percent of total billed charges,,,60,,460.8,percent of total billed charges,,460.8,729.6,
BALLOON DILATORS CRE 15-16.6-18MM,101488,CDM,278,RC,C1726,HCPCS,,,Inpatient,,,768,,,,80,,614.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,596.74,percent of total billed charges,,,95,,729.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,729.6,
SYRINGE AND GUAGE ASSEMBLY,101489,CDM,270,RC,,,,,Outpatient,,,113.1,,,,80,,90.48,percent of total billed charges,,,,85,96.14,percent of total billed charges,,,77.7,,87.88,percent of total billed charges,,,95,,107.45,percent of total billed charges,,,60,,67.86,percent of total billed charges,,67.86,107.45,
SYRINGE AND GUAGE ASSEMBLY,101489,CDM,270,RC,,,,,Inpatient,,,113.1,,,,80,,90.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,87.88,percent of total billed charges,,,95,,107.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,107.45,
PLEURX DRAINAGE KIT 500ML,101492,CDM,270,RC,,,,,Outpatient,,,295.1,,,,80,,236.08,percent of total billed charges,,,,85,250.84,percent of total billed charges,,,77.7,,229.29,percent of total billed charges,,,95,,280.35,percent of total billed charges,,,60,,177.06,percent of total billed charges,,177.06,280.35,
PLEURX DRAINAGE KIT 500ML,101492,CDM,270,RC,,,,,Inpatient,,,295.1,,,,80,,236.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,229.29,percent of total billed charges,,,95,,280.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,280.35,
"NEEDLE EPIDURAL 20g x 6"" TUOHY",101497,CDM,270,RC,,,,,Outpatient,,,73.7,,,,80,,58.96,percent of total billed charges,,,,85,62.65,percent of total billed charges,,,77.7,,57.26,percent of total billed charges,,,95,,70.02,percent of total billed charges,,,60,,44.22,percent of total billed charges,,44.22,70.02,
"NEEDLE EPIDURAL 20g x 6"" TUOHY",101497,CDM,270,RC,,,,,Inpatient,,,73.7,,,,80,,58.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,57.26,percent of total billed charges,,,95,,70.02,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,70.02,
ANESTHESIA  ANTI SYPHON LINE,101498,CDM,270,RC,,,,,Outpatient,,,18.1,,,,80,,14.48,percent of total billed charges,,,,85,15.39,percent of total billed charges,,,77.7,,14.06,percent of total billed charges,,,95,,17.2,percent of total billed charges,,,60,,10.86,percent of total billed charges,,10.86,17.2,
ANESTHESIA  ANTI SYPHON LINE,101498,CDM,270,RC,,,,,Inpatient,,,18.1,,,,80,,14.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.06,percent of total billed charges,,,95,,17.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.2,
LIGACLIP SMALL MULTI CLIP APPLIER,101499,CDM,270,RC,,,,,Outpatient,,,192.5,,,,80,,154,percent of total billed charges,,,,85,163.63,percent of total billed charges,,,77.7,,149.57,percent of total billed charges,,,95,,182.88,percent of total billed charges,,,60,,115.5,percent of total billed charges,,115.5,182.88,
LIGACLIP SMALL MULTI CLIP APPLIER,101499,CDM,270,RC,,,,,Inpatient,,,192.5,,,,80,,154,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,149.57,percent of total billed charges,,,95,,182.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,182.88,
MESH LIGHT PLUG MED BARD/DAVOL,101500,CDM,278,RC,C1781,HCPCS,,,Outpatient,,,367.5,,,,80,,294,percent of total billed charges,,,,85,312.38,percent of total billed charges,,,77.7,,285.55,percent of total billed charges,,,95,,349.13,percent of total billed charges,,,60,,220.5,percent of total billed charges,,220.5,349.13,
MESH LIGHT PLUG MED BARD/DAVOL,101500,CDM,278,RC,C1781,HCPCS,,,Inpatient,,,367.5,,,,80,,294,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,285.55,percent of total billed charges,,,95,,349.13,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,349.13,
BITE BLOCK WITH STRAP ADULT,101503,CDM,270,RC,,,,,Outpatient,,,3.3,,,,80,,2.64,percent of total billed charges,,,,85,2.81,percent of total billed charges,,,77.7,,2.56,percent of total billed charges,,,95,,3.14,percent of total billed charges,,,60,,1.98,percent of total billed charges,,1.98,3.14,
BITE BLOCK WITH STRAP ADULT,101503,CDM,270,RC,,,,,Inpatient,,,3.3,,,,80,,2.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.56,percent of total billed charges,,,95,,3.14,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.14,
STOOL MANAGEMENT SYSTEM,101505,CDM,270,RC,,,,,Outpatient,,,429.9,,,,80,,343.92,percent of total billed charges,,,,85,365.42,percent of total billed charges,,,77.7,,334.03,percent of total billed charges,,,95,,408.41,percent of total billed charges,,,60,,257.94,percent of total billed charges,,257.94,408.41,
STOOL MANAGEMENT SYSTEM,101505,CDM,270,RC,,,,,Inpatient,,,429.9,,,,80,,343.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,334.03,percent of total billed charges,,,95,,408.41,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,408.41,
STOOL MANAGEMENT COLLECTION BAG,101506,CDM,270,RC,,,,,Outpatient,,,12.3,,,,80,,9.84,percent of total billed charges,,,,85,10.46,percent of total billed charges,,,77.7,,9.56,percent of total billed charges,,,95,,11.69,percent of total billed charges,,,60,,7.38,percent of total billed charges,,7.38,11.69,
STOOL MANAGEMENT COLLECTION BAG,101506,CDM,270,RC,,,,,Inpatient,,,12.3,,,,80,,9.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.56,percent of total billed charges,,,95,,11.69,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.69,
FOLEY CATH TUBE 22FR 30CC,101507,CDM,270,RC,,,,,Outpatient,,,6.2,,,,80,,4.96,percent of total billed charges,,,,85,5.27,percent of total billed charges,,,77.7,,4.82,percent of total billed charges,,,95,,5.89,percent of total billed charges,,,60,,3.72,percent of total billed charges,,3.72,5.89,
FOLEY CATH TUBE 22FR 30CC,101507,CDM,270,RC,,,,,Inpatient,,,6.2,,,,80,,4.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.82,percent of total billed charges,,,95,,5.89,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.89,
RELIEVA BALLOON SPIN SINUPLASTY SYSTEM,101508,CDM,278,RC,C1726,HCPCS,,,Outpatient,,,1120,,,,80,,896,percent of total billed charges,,,,85,952,percent of total billed charges,,,77.7,,870.24,percent of total billed charges,,,95,,1064,percent of total billed charges,,,60,,672,percent of total billed charges,,672,1064,
RELIEVA BALLOON SPIN SINUPLASTY SYSTEM,101508,CDM,278,RC,C1726,HCPCS,,,Inpatient,,,1120,,,,80,,896,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,870.24,percent of total billed charges,,,95,,1064,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1064,
POSTURE SUPPORT M/L,101509,CDM,270,RC,,,,,Outpatient,,,66.5,,,,80,,53.2,percent of total billed charges,,,,85,56.53,percent of total billed charges,,,77.7,,51.67,percent of total billed charges,,,95,,63.18,percent of total billed charges,,,60,,39.9,percent of total billed charges,,39.9,63.18,
POSTURE SUPPORT M/L,101509,CDM,270,RC,,,,,Inpatient,,,66.5,,,,80,,53.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,51.67,percent of total billed charges,,,95,,63.18,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,63.18,
MEPILEX BORDER SACRUM,101510,CDM,270,RC,,,,,Outpatient,,,25,,,,80,,20,percent of total billed charges,,,,85,21.25,percent of total billed charges,,,77.7,,19.43,percent of total billed charges,,,95,,23.75,percent of total billed charges,,,60,,15,percent of total billed charges,,15,23.75,
MEPILEX BORDER SACRUM,101510,CDM,270,RC,,,,,Inpatient,,,25,,,,80,,20,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.43,percent of total billed charges,,,95,,23.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,23.75,
BONEWAX 2.5 GR,101511,CDM,270,RC,,,,,Outpatient,,,3.1,,,,80,,2.48,percent of total billed charges,,,,85,2.64,percent of total billed charges,,,77.7,,2.41,percent of total billed charges,,,95,,2.95,percent of total billed charges,,,60,,1.86,percent of total billed charges,,1.86,2.95,
BONEWAX 2.5 GR,101511,CDM,270,RC,,,,,Inpatient,,,3.1,,,,80,,2.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.41,percent of total billed charges,,,95,,2.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.95,
L1902 ANKLE LACE UP XSMALL,101519,CDM,274,RC,L1902,HCPCS,,,Outpatient,,,44.5,,,,80,,35.6,percent of total billed charges,,,,85,37.83,percent of total billed charges,,,77.7,,34.58,percent of total billed charges,,,95,,42.28,percent of total billed charges,,,60,,26.7,percent of total billed charges,,26.7,42.28,
L1902 ANKLE LACE UP XSMALL,101519,CDM,274,RC,L1902,HCPCS,,,Inpatient,,,44.5,,,,80,,35.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,34.58,percent of total billed charges,,,95,,42.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,42.28,
L1902 ANKLE LACE UP SMALL,101520,CDM,274,RC,L1902,HCPCS,,,Outpatient,,,44,,,,80,,35.2,percent of total billed charges,,,,85,37.4,percent of total billed charges,,,77.7,,34.19,percent of total billed charges,,,95,,41.8,percent of total billed charges,,,60,,26.4,percent of total billed charges,,26.4,41.8,
L1902 ANKLE LACE UP SMALL,101520,CDM,274,RC,L1902,HCPCS,,,Inpatient,,,44,,,,80,,35.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,34.19,percent of total billed charges,,,95,,41.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,41.8,
ANKLE LACE UP MEDIUM,101521,CDM,274,RC,L1902,HCPCS,,,Outpatient,,,37.1,,,,80,,29.68,percent of total billed charges,,,,85,31.54,percent of total billed charges,,,77.7,,28.83,percent of total billed charges,,,95,,35.25,percent of total billed charges,,,60,,22.26,percent of total billed charges,,22.26,35.25,
ANKLE LACE UP MEDIUM,101521,CDM,274,RC,L1902,HCPCS,,,Inpatient,,,37.1,,,,80,,29.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,28.83,percent of total billed charges,,,95,,35.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,35.25,
L1902 ANKLE LACE UP LARGE,101522,CDM,274,RC,L1902,HCPCS,,,Outpatient,,,37.1,,,,80,,29.68,percent of total billed charges,,,,85,31.54,percent of total billed charges,,,77.7,,28.83,percent of total billed charges,,,95,,35.25,percent of total billed charges,,,60,,22.26,percent of total billed charges,,22.26,35.25,
L1902 ANKLE LACE UP LARGE,101522,CDM,274,RC,L1902,HCPCS,,,Inpatient,,,37.1,,,,80,,29.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,28.83,percent of total billed charges,,,95,,35.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,35.25,
L1902 ANKLE LACE UP XLARGE,101523,CDM,274,RC,L1902,HCPCS,,,Outpatient,,,37.1,,,,80,,29.68,percent of total billed charges,,,,85,31.54,percent of total billed charges,,,77.7,,28.83,percent of total billed charges,,,95,,35.25,percent of total billed charges,,,60,,22.26,percent of total billed charges,,22.26,35.25,
L1902 ANKLE LACE UP XLARGE,101523,CDM,274,RC,L1902,HCPCS,,,Inpatient,,,37.1,,,,80,,29.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,28.83,percent of total billed charges,,,95,,35.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,35.25,
TENNIS ELBOW SPLINT,101524,CDM,274,RC,L1930,HCPCS,,,Outpatient,,,7.1,,,,80,,5.68,percent of total billed charges,,,,50,158.94,fee schedule,,,77.7,,5.52,percent of total billed charges,,,95,,6.75,percent of total billed charges,,,60,,4.26,percent of total billed charges,,4.26,158.94,
TENNIS ELBOW SPLINT,101524,CDM,274,RC,L1930,HCPCS,,,Inpatient,,,7.1,,,,80,,5.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.52,percent of total billed charges,,,95,,6.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.75,
WRIST THUMB XLG RT SPLINT,101525,CDM,270,RC,,,,,Outpatient,,,51.7,,,,80,,41.36,percent of total billed charges,,,,85,43.95,percent of total billed charges,,,77.7,,40.17,percent of total billed charges,,,95,,49.12,percent of total billed charges,,,60,,31.02,percent of total billed charges,,31.02,49.12,
WRIST THUMB XLG RT SPLINT,101525,CDM,270,RC,,,,,Inpatient,,,51.7,,,,80,,41.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,40.17,percent of total billed charges,,,95,,49.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,49.12,
WRIST THUMB XLG LT SPLINT,101526,CDM,274,RC,L3809,HCPCS,,,Outpatient,,,51.7,,,,80,,41.36,percent of total billed charges,,,,85,43.95,percent of total billed charges,,,77.7,,40.17,percent of total billed charges,,,95,,49.12,percent of total billed charges,,,60,,31.02,percent of total billed charges,,31.02,49.12,
WRIST THUMB XLG LT SPLINT,101526,CDM,274,RC,L3809,HCPCS,,,Inpatient,,,51.7,,,,80,,41.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,40.17,percent of total billed charges,,,95,,49.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,49.12,
"NEEDLE EPIDURAL 17g x 5"" TUOHY",101527,CDM,270,RC,,,,,Outpatient,,,56.4,,,,80,,45.12,percent of total billed charges,,,,85,47.94,percent of total billed charges,,,77.7,,43.82,percent of total billed charges,,,95,,53.58,percent of total billed charges,,,60,,33.84,percent of total billed charges,,33.84,53.58,
"NEEDLE EPIDURAL 17g x 5"" TUOHY",101527,CDM,270,RC,,,,,Inpatient,,,56.4,,,,80,,45.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,43.82,percent of total billed charges,,,95,,53.58,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,53.58,
DERMA BLADE SHAVER,101530,CDM,270,RC,,,,,Outpatient,,,5.8,,,,80,,4.64,percent of total billed charges,,,,85,4.93,percent of total billed charges,,,77.7,,4.51,percent of total billed charges,,,95,,5.51,percent of total billed charges,,,60,,3.48,percent of total billed charges,,3.48,5.51,
DERMA BLADE SHAVER,101530,CDM,270,RC,,,,,Inpatient,,,5.8,,,,80,,4.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.51,percent of total billed charges,,,95,,5.51,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.51,
ENTELLUS MULTI-SINUS LOW PROFILE,101531,CDM,278,RC,C1726,HCPCS,,,Outpatient,,,6387.5,,,,80,,5110,percent of total billed charges,,,,85,5429.38,percent of total billed charges,,,77.7,,4963.09,percent of total billed charges,,,95,,6068.13,percent of total billed charges,,,60,,3832.5,percent of total billed charges,,3832.5,6068.13,
ENTELLUS MULTI-SINUS LOW PROFILE,101531,CDM,278,RC,C1726,HCPCS,,,Inpatient,,,6387.5,,,,80,,5110,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4963.09,percent of total billed charges,,,95,,6068.13,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6068.13,
NASAL AIRWAY 26FR LF PVC,101533,CDM,270,RC,,,,,Outpatient,,,6.2,,,,80,,4.96,percent of total billed charges,,,,85,5.27,percent of total billed charges,,,77.7,,4.82,percent of total billed charges,,,95,,5.89,percent of total billed charges,,,60,,3.72,percent of total billed charges,,3.72,5.89,
NASAL AIRWAY 26FR LF PVC,101533,CDM,270,RC,,,,,Inpatient,,,6.2,,,,80,,4.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.82,percent of total billed charges,,,95,,5.89,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.89,
NASAL AIRWAY 28FR LF PVC,101534,CDM,270,RC,,,,,Outpatient,,,6.4,,,,80,,5.12,percent of total billed charges,,,,85,5.44,percent of total billed charges,,,77.7,,4.97,percent of total billed charges,,,95,,6.08,percent of total billed charges,,,60,,3.84,percent of total billed charges,,3.84,6.08,
NASAL AIRWAY 28FR LF PVC,101534,CDM,270,RC,,,,,Inpatient,,,6.4,,,,80,,5.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.97,percent of total billed charges,,,95,,6.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.08,
NASAL AIRWAY 30FR LF PVC,101535,CDM,270,RC,,,,,Outpatient,,,6.4,,,,80,,5.12,percent of total billed charges,,,,85,5.44,percent of total billed charges,,,77.7,,4.97,percent of total billed charges,,,95,,6.08,percent of total billed charges,,,60,,3.84,percent of total billed charges,,3.84,6.08,
NASAL AIRWAY 30FR LF PVC,101535,CDM,270,RC,,,,,Inpatient,,,6.4,,,,80,,5.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.97,percent of total billed charges,,,95,,6.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.08,
NASAL AIRWAY 32FR LF PVC,101536,CDM,270,RC,,,,,Outpatient,,,6.4,,,,80,,5.12,percent of total billed charges,,,,85,5.44,percent of total billed charges,,,77.7,,4.97,percent of total billed charges,,,95,,6.08,percent of total billed charges,,,60,,3.84,percent of total billed charges,,3.84,6.08,
NASAL AIRWAY 32FR LF PVC,101536,CDM,270,RC,,,,,Inpatient,,,6.4,,,,80,,5.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.97,percent of total billed charges,,,95,,6.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.08,
RETRO ARC SLING,101537,CDM,278,RC,C1771,HCPCS,,,Outpatient,,,55.2,,,,80,,44.16,percent of total billed charges,,,,85,46.92,percent of total billed charges,,,77.7,,42.89,percent of total billed charges,,,95,,52.44,percent of total billed charges,,,60,,33.12,percent of total billed charges,,33.12,52.44,
RETRO ARC SLING,101537,CDM,278,RC,C1771,HCPCS,,,Inpatient,,,55.2,,,,80,,44.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,42.89,percent of total billed charges,,,95,,52.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,52.44,
LONE STAR RETRACTABLE STAYS,101538,CDM,270,RC,,,,,Outpatient,,,32.9,,,,80,,26.32,percent of total billed charges,,,,85,27.97,percent of total billed charges,,,77.7,,25.56,percent of total billed charges,,,95,,31.26,percent of total billed charges,,,60,,19.74,percent of total billed charges,,19.74,31.26,
LONE STAR RETRACTABLE STAYS,101538,CDM,270,RC,,,,,Inpatient,,,32.9,,,,80,,26.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,25.56,percent of total billed charges,,,95,,31.26,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,31.26,
PRISMA DRESSING 4.1 SQUARE,101542,CDM,623,RC,A6129,HCPCS,,,Outpatient,,,28.9,,,,80,,23.12,percent of total billed charges,,,,85,24.57,percent of total billed charges,,,77.7,,22.46,percent of total billed charges,,,95,,27.46,percent of total billed charges,,,60,,17.34,percent of total billed charges,,17.34,27.46,
PRISMA DRESSING 4.1 SQUARE,101542,CDM,623,RC,A6129,HCPCS,,,Inpatient,,,28.9,,,,80,,23.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,22.46,percent of total billed charges,,,95,,27.46,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,27.46,
SENSOR STRAIGHT TIP 0.038 X 150CM,101546,CDM,270,RC,,,,,Outpatient,,,258.3,,,,80,,206.64,percent of total billed charges,,,,85,219.56,percent of total billed charges,,,77.7,,200.7,percent of total billed charges,,,95,,245.39,percent of total billed charges,,,60,,154.98,percent of total billed charges,,154.98,245.39,
SENSOR STRAIGHT TIP 0.038 X 150CM,101546,CDM,270,RC,,,,,Inpatient,,,258.3,,,,80,,206.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,200.7,percent of total billed charges,,,95,,245.39,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,245.39,
URETERAL STENT 6FR X 28CM,101547,CDM,278,RC,C2617,HCPCS,,,Outpatient,,,390.3,,,,80,,312.24,percent of total billed charges,,,,85,331.76,percent of total billed charges,,,77.7,,303.26,percent of total billed charges,,,95,,370.79,percent of total billed charges,,,60,,234.18,percent of total billed charges,,234.18,370.79,
URETERAL STENT 6FR X 28CM,101547,CDM,278,RC,C2617,HCPCS,,,Inpatient,,,390.3,,,,80,,312.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,303.26,percent of total billed charges,,,95,,370.79,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,370.79,
URETERAL CATHETER 6 FR,101548,CDM,270,RC,,,,,Outpatient,,,33,,,,80,,26.4,percent of total billed charges,,,,85,28.05,percent of total billed charges,,,77.7,,25.64,percent of total billed charges,,,95,,31.35,percent of total billed charges,,,60,,19.8,percent of total billed charges,,19.8,31.35,
URETERAL CATHETER 6 FR,101548,CDM,270,RC,,,,,Inpatient,,,33,,,,80,,26.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,25.64,percent of total billed charges,,,95,,31.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,31.35,
URETERAL STENT 6 FR X 26CM,101549,CDM,278,RC,C2617,HCPCS,,,Outpatient,,,111.6,,,,80,,89.28,percent of total billed charges,,,,85,94.86,percent of total billed charges,,,77.7,,86.71,percent of total billed charges,,,95,,106.02,percent of total billed charges,,,60,,66.96,percent of total billed charges,,66.96,106.02,
URETERAL STENT 6 FR X 26CM,101549,CDM,278,RC,C2617,HCPCS,,,Inpatient,,,111.6,,,,80,,89.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,86.71,percent of total billed charges,,,95,,106.02,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,106.02,
SKIN TEMP PROBE GE,101550,CDM,270,RC,,,,,Outpatient,,,11.8,,,,80,,9.44,percent of total billed charges,,,,85,10.03,percent of total billed charges,,,77.7,,9.17,percent of total billed charges,,,95,,11.21,percent of total billed charges,,,60,,7.08,percent of total billed charges,,7.08,11.21,
SKIN TEMP PROBE GE,101550,CDM,270,RC,,,,,Inpatient,,,11.8,,,,80,,9.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.17,percent of total billed charges,,,95,,11.21,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.21,
BIOPSY GUIDE W/COVER,101551,CDM,270,RC,,,,,Outpatient,,,58.1,,,,80,,46.48,percent of total billed charges,,,,85,49.39,percent of total billed charges,,,77.7,,45.14,percent of total billed charges,,,95,,55.2,percent of total billed charges,,,60,,34.86,percent of total billed charges,,34.86,55.2,
BIOPSY GUIDE W/COVER,101551,CDM,270,RC,,,,,Inpatient,,,58.1,,,,80,,46.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,45.14,percent of total billed charges,,,95,,55.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,55.2,
BIOPSY MONOPTY CORE DISPOSABLE,101552,CDM,270,RC,,,,,Outpatient,,,200.9,,,,80,,160.72,percent of total billed charges,,,,85,170.77,percent of total billed charges,,,77.7,,156.1,percent of total billed charges,,,95,,190.86,percent of total billed charges,,,60,,120.54,percent of total billed charges,,120.54,190.86,
BIOPSY MONOPTY CORE DISPOSABLE,101552,CDM,270,RC,,,,,Inpatient,,,200.9,,,,80,,160.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,156.1,percent of total billed charges,,,95,,190.86,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,190.86,
PROPEL MOMETASONE FUROATE IMPLANT,101553,CDM,278,RC,C2625,HCPCS,,,Outpatient,,,2975,,,,80,,2380,percent of total billed charges,,,,85,2528.75,percent of total billed charges,,,77.7,,2311.58,percent of total billed charges,,,95,,2826.25,percent of total billed charges,,,60,,1785,percent of total billed charges,,1785,2826.25,
PROPEL MOMETASONE FUROATE IMPLANT,101553,CDM,278,RC,C2625,HCPCS,,,Inpatient,,,2975,,,,80,,2380,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2311.58,percent of total billed charges,,,95,,2826.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2826.25,
NEEDLE BONEE INJECTION 22G,101556,CDM,270,RC,,,,,Outpatient,,,274.1,,,,80,,219.28,percent of total billed charges,,,,85,232.99,percent of total billed charges,,,77.7,,212.98,percent of total billed charges,,,95,,260.4,percent of total billed charges,,,60,,164.46,percent of total billed charges,,164.46,260.4,
NEEDLE BONEE INJECTION 22G,101556,CDM,270,RC,,,,,Inpatient,,,274.1,,,,80,,219.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,212.98,percent of total billed charges,,,95,,260.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,260.4,
PREVENT PULMONARY FUNCTION FILTER,101557,CDM,270,RC,,,,,Outpatient,,,6,,,,80,,4.8,percent of total billed charges,,,,85,5.1,percent of total billed charges,,,77.7,,4.66,percent of total billed charges,,,95,,5.7,percent of total billed charges,,,60,,3.6,percent of total billed charges,,3.6,5.7,
PREVENT PULMONARY FUNCTION FILTER,101557,CDM,270,RC,,,,,Inpatient,,,6,,,,80,,4.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.66,percent of total billed charges,,,95,,5.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.7,
STATLOCK PICC LINE SLIDING POST,101559,CDM,270,RC,,,,,Outpatient,,,13.2,,,,80,,10.56,percent of total billed charges,,,,85,11.22,percent of total billed charges,,,77.7,,10.26,percent of total billed charges,,,95,,12.54,percent of total billed charges,,,60,,7.92,percent of total billed charges,,7.92,12.54,
STATLOCK PICC LINE SLIDING POST,101559,CDM,270,RC,,,,,Inpatient,,,13.2,,,,80,,10.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.26,percent of total billed charges,,,95,,12.54,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,12.54,
ARM SLEEVE RT MED FULL FINGER GLOVE,101562,CDM,270,RC,,,,,Outpatient,,,62.6,,,,80,,50.08,percent of total billed charges,,,,85,53.21,percent of total billed charges,,,77.7,,48.64,percent of total billed charges,,,95,,59.47,percent of total billed charges,,,60,,37.56,percent of total billed charges,,37.56,59.47,
ARM SLEEVE RT MED FULL FINGER GLOVE,101562,CDM,270,RC,,,,,Inpatient,,,62.6,,,,80,,50.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,48.64,percent of total billed charges,,,95,,59.47,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,59.47,
LONE STAR RETRACTABLE,101563,CDM,270,RC,,,,,Outpatient,,,32.9,,,,80,,26.32,percent of total billed charges,,,,85,27.97,percent of total billed charges,,,77.7,,25.56,percent of total billed charges,,,95,,31.26,percent of total billed charges,,,60,,19.74,percent of total billed charges,,19.74,31.26,
LONE STAR RETRACTABLE,101563,CDM,270,RC,,,,,Inpatient,,,32.9,,,,80,,26.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,25.56,percent of total billed charges,,,95,,31.26,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,31.26,
ELECTRODE LOOP 27FR,101571,CDM,270,RC,,,,,Outpatient,,,122.5,,,,80,,98,percent of total billed charges,,,,85,104.13,percent of total billed charges,,,77.7,,95.18,percent of total billed charges,,,95,,116.38,percent of total billed charges,,,60,,73.5,percent of total billed charges,,73.5,116.38,
ELECTRODE LOOP 27FR,101571,CDM,270,RC,,,,,Inpatient,,,122.5,,,,80,,98,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,95.18,percent of total billed charges,,,95,,116.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,116.38,
ELECTRODE BALL 24FR 3MM,101572,CDM,270,RC,,,,,Outpatient,,,161,,,,80,,128.8,percent of total billed charges,,,,85,136.85,percent of total billed charges,,,77.7,,125.1,percent of total billed charges,,,95,,152.95,percent of total billed charges,,,60,,96.6,percent of total billed charges,,96.6,152.95,
ELECTRODE BALL 24FR 3MM,101572,CDM,270,RC,,,,,Inpatient,,,161,,,,80,,128.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,125.1,percent of total billed charges,,,95,,152.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,152.95,
FOLEY CATH 22FR 3OCC 3WAY,101573,CDM,270,RC,,,,,Outpatient,,,33.2,,,,80,,26.56,percent of total billed charges,,,,85,28.22,percent of total billed charges,,,77.7,,25.8,percent of total billed charges,,,95,,31.54,percent of total billed charges,,,60,,19.92,percent of total billed charges,,19.92,31.54,
FOLEY CATH 22FR 3OCC 3WAY,101573,CDM,270,RC,,,,,Inpatient,,,33.2,,,,80,,26.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,25.8,percent of total billed charges,,,95,,31.54,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,31.54,
DISPOCAP BIOPSY CAP,101575,CDM,270,RC,,,,,Outpatient,,,3,,,,80,,2.4,percent of total billed charges,,,,85,2.55,percent of total billed charges,,,77.7,,2.33,percent of total billed charges,,,95,,2.85,percent of total billed charges,,,60,,1.8,percent of total billed charges,,1.8,2.85,
DISPOCAP BIOPSY CAP,101575,CDM,270,RC,,,,,Inpatient,,,3,,,,80,,2.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.33,percent of total billed charges,,,95,,2.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.85,
CO2 MICROLINE FILTER W AIRWAY ADAPTER,101582,CDM,270,RC,,,,,Outpatient,,,33.8,,,,80,,27.04,percent of total billed charges,,,,85,28.73,percent of total billed charges,,,77.7,,26.26,percent of total billed charges,,,95,,32.11,percent of total billed charges,,,60,,20.28,percent of total billed charges,,20.28,32.11,
CO2 MICROLINE FILTER W AIRWAY ADAPTER,101582,CDM,270,RC,,,,,Inpatient,,,33.8,,,,80,,27.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,26.26,percent of total billed charges,,,95,,32.11,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,32.11,
SUCTION CATHETER 16F W/G,101585,CDM,270,RC,,,,,Outpatient,,,2.1,,,,80,,1.68,percent of total billed charges,,,,85,1.79,percent of total billed charges,,,77.7,,1.63,percent of total billed charges,,,95,,2,percent of total billed charges,,,60,,1.26,percent of total billed charges,,1.26,2,
SUCTION CATHETER 16F W/G,101585,CDM,270,RC,,,,,Inpatient,,,2.1,,,,80,,1.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.63,percent of total billed charges,,,95,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2,
ZERO-G HEEL PILLOW SINGLE,101588,CDM,270,RC,,,,,Outpatient,,,204,,,,80,,163.2,percent of total billed charges,,,,85,173.4,percent of total billed charges,,,77.7,,158.51,percent of total billed charges,,,95,,193.8,percent of total billed charges,,,60,,122.4,percent of total billed charges,,122.4,193.8,
ZERO-G HEEL PILLOW SINGLE,101588,CDM,270,RC,,,,,Inpatient,,,204,,,,80,,163.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,158.51,percent of total billed charges,,,95,,193.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,193.8,
ELECTRODE LOOP 15MM X 8MM,101589,CDM,270,RC,,,,,Outpatient,,,68.5,,,,80,,54.8,percent of total billed charges,,,,85,58.23,percent of total billed charges,,,77.7,,53.22,percent of total billed charges,,,95,,65.08,percent of total billed charges,,,60,,41.1,percent of total billed charges,,41.1,65.08,
ELECTRODE LOOP 15MM X 8MM,101589,CDM,270,RC,,,,,Inpatient,,,68.5,,,,80,,54.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,53.22,percent of total billed charges,,,95,,65.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,65.08,
LARYNGEAL AIRWAY PVC  #4,101590,CDM,270,RC,,,,,Outpatient,,,38.9,,,,80,,31.12,percent of total billed charges,,,,85,33.07,percent of total billed charges,,,77.7,,30.23,percent of total billed charges,,,95,,36.96,percent of total billed charges,,,60,,23.34,percent of total billed charges,,23.34,36.96,
LARYNGEAL AIRWAY PVC  #4,101590,CDM,270,RC,,,,,Inpatient,,,38.9,,,,80,,31.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,30.23,percent of total billed charges,,,95,,36.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,36.96,
OPTIFOAM AG 3.5X14,101593,CDM,270,RC,,,,,Outpatient,,,92.7,,,,80,,74.16,percent of total billed charges,,,,85,78.8,percent of total billed charges,,,77.7,,72.03,percent of total billed charges,,,95,,88.07,percent of total billed charges,,,60,,55.62,percent of total billed charges,,55.62,88.07,
OPTIFOAM AG 3.5X14,101593,CDM,270,RC,,,,,Inpatient,,,92.7,,,,80,,74.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,72.03,percent of total billed charges,,,95,,88.07,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,88.07,
OPTIFOAM AG 3.5 X 6,101594,CDM,270,RC,,,,,Outpatient,,,68.6,,,,80,,54.88,percent of total billed charges,,,,85,58.31,percent of total billed charges,,,77.7,,53.3,percent of total billed charges,,,95,,65.17,percent of total billed charges,,,60,,41.16,percent of total billed charges,,41.16,65.17,
OPTIFOAM AG 3.5 X 6,101594,CDM,270,RC,,,,,Inpatient,,,68.6,,,,80,,54.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,53.3,percent of total billed charges,,,95,,65.17,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,65.17,
HEEL PROTECTOR LARGE,101595,CDM,270,RC,,,,,Outpatient,,,73.8,,,,80,,59.04,percent of total billed charges,,,,85,62.73,percent of total billed charges,,,77.7,,57.34,percent of total billed charges,,,95,,70.11,percent of total billed charges,,,60,,44.28,percent of total billed charges,,44.28,70.11,
HEEL PROTECTOR LARGE,101595,CDM,270,RC,,,,,Inpatient,,,73.8,,,,80,,59.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,57.34,percent of total billed charges,,,95,,70.11,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,70.11,
HEEL PROTECTOR X-LARGE,101596,CDM,270,RC,,,,,Outpatient,,,73.8,,,,80,,59.04,percent of total billed charges,,,,85,62.73,percent of total billed charges,,,77.7,,57.34,percent of total billed charges,,,95,,70.11,percent of total billed charges,,,60,,44.28,percent of total billed charges,,44.28,70.11,
HEEL PROTECTOR X-LARGE,101596,CDM,270,RC,,,,,Inpatient,,,73.8,,,,80,,59.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,57.34,percent of total billed charges,,,95,,70.11,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,70.11,
VASELINE GAUZE DRESSING 1 X 8,101597,CDM,270,RC,,,,,Outpatient,,,1.5,,,,80,,1.2,percent of total billed charges,,,,85,1.28,percent of total billed charges,,,77.7,,1.17,percent of total billed charges,,,95,,1.43,percent of total billed charges,,,60,,0.9,percent of total billed charges,,0.9,1.43,
VASELINE GAUZE DRESSING 1 X 8,101597,CDM,270,RC,,,,,Inpatient,,,1.5,,,,80,,1.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.17,percent of total billed charges,,,95,,1.43,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.43,
MESH ADVANTAGE FIT,101601,CDM,278,RC,C1781,HCPCS,,,Outpatient,,,2786.9,,,,80,,2229.52,percent of total billed charges,,,,85,2368.87,percent of total billed charges,,,77.7,,2165.42,percent of total billed charges,,,95,,2647.56,percent of total billed charges,,,60,,1672.14,percent of total billed charges,,1672.14,2647.56,
MESH ADVANTAGE FIT,101601,CDM,278,RC,C1781,HCPCS,,,Inpatient,,,2786.9,,,,80,,2229.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2165.42,percent of total billed charges,,,95,,2647.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2647.56,
DIALATORS RENAL AMPLATZ SHEATH SET,101602,CDM,270,RC,,,,,Outpatient,,,1480.5,,,,80,,1184.4,percent of total billed charges,,,,85,1258.43,percent of total billed charges,,,77.7,,1150.35,percent of total billed charges,,,95,,1406.48,percent of total billed charges,,,60,,888.3,percent of total billed charges,,888.3,1406.48,
DIALATORS RENAL AMPLATZ SHEATH SET,101602,CDM,270,RC,,,,,Inpatient,,,1480.5,,,,80,,1184.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1150.35,percent of total billed charges,,,95,,1406.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1406.48,
"ACE BANDAGE 4"" LF STERILE",101603,CDM,623,RC,A6441,HCPCS,,,Outpatient,,,4.2,,,,80,,3.36,percent of total billed charges,,,,50,0.38,fee schedule,,,77.7,,3.26,percent of total billed charges,,,95,,3.99,percent of total billed charges,,,60,,2.52,percent of total billed charges,,0.38,3.99,
"ACE BANDAGE 4"" LF STERILE",101603,CDM,623,RC,A6441,HCPCS,,,Inpatient,,,4.2,,,,80,,3.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.26,percent of total billed charges,,,95,,3.99,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.99,
"ESMARK BANDAGE 4"" X 12' LF STERILE",101604,CDM,270,RC,,,,,Outpatient,,,11.8,,,,80,,9.44,percent of total billed charges,,,,85,10.03,percent of total billed charges,,,77.7,,9.17,percent of total billed charges,,,95,,11.21,percent of total billed charges,,,60,,7.08,percent of total billed charges,,7.08,11.21,
"ESMARK BANDAGE 4"" X 12' LF STERILE",101604,CDM,270,RC,,,,,Inpatient,,,11.8,,,,80,,9.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.17,percent of total billed charges,,,95,,11.21,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.21,
PLEURX DRAINAGE KIT 1000ML,101607,CDM,270,RC,,,,,Outpatient,,,37.6,,,,80,,30.08,percent of total billed charges,,,,85,31.96,percent of total billed charges,,,77.7,,29.22,percent of total billed charges,,,95,,35.72,percent of total billed charges,,,60,,22.56,percent of total billed charges,,22.56,35.72,
PLEURX DRAINAGE KIT 1000ML,101607,CDM,270,RC,,,,,Inpatient,,,37.6,,,,80,,30.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,29.22,percent of total billed charges,,,95,,35.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,35.72,
IODAFLEX CADEXOMER 4CM X 6 CM  5 GM,101608,CDM,270,RC,,,,,Outpatient,,,23,,,,80,,18.4,percent of total billed charges,,,,85,19.55,percent of total billed charges,,,77.7,,17.87,percent of total billed charges,,,95,,21.85,percent of total billed charges,,,60,,13.8,percent of total billed charges,,13.8,21.85,
IODAFLEX CADEXOMER 4CM X 6 CM  5 GM,101608,CDM,270,RC,,,,,Inpatient,,,23,,,,80,,18.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,17.87,percent of total billed charges,,,95,,21.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,21.85,
SERFAS ENERGY ABILATION SYSTEM 90-S,101609,CDM,278,RC,C1769,HCPCS,,,Outpatient,,,700,,,,80,,560,percent of total billed charges,,,,85,595,percent of total billed charges,,,77.7,,543.9,percent of total billed charges,,,95,,665,percent of total billed charges,,,60,,420,percent of total billed charges,,420,665,
SERFAS ENERGY ABILATION SYSTEM 90-S,101609,CDM,278,RC,C1769,HCPCS,,,Inpatient,,,700,,,,80,,560,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,543.9,percent of total billed charges,,,95,,665,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,665,
CANNULA TENDER GRIP INFANT,101610,CDM,270,RC,,,,,Outpatient,,,13.1,,,,80,,10.48,percent of total billed charges,,,,85,11.14,percent of total billed charges,,,77.7,,10.18,percent of total billed charges,,,95,,12.45,percent of total billed charges,,,60,,7.86,percent of total billed charges,,7.86,12.45,
CANNULA TENDER GRIP INFANT,101610,CDM,270,RC,,,,,Inpatient,,,13.1,,,,80,,10.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.18,percent of total billed charges,,,95,,12.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,12.45,
CANNULA TENDER GRIP NEWBORN,101611,CDM,270,RC,,,,,Outpatient,,,13.1,,,,80,,10.48,percent of total billed charges,,,,85,11.14,percent of total billed charges,,,77.7,,10.18,percent of total billed charges,,,95,,12.45,percent of total billed charges,,,60,,7.86,percent of total billed charges,,7.86,12.45,
CANNULA TENDER GRIP NEWBORN,101611,CDM,270,RC,,,,,Inpatient,,,13.1,,,,80,,10.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.18,percent of total billed charges,,,95,,12.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,12.45,
CANNULA TENDER GRIP ADULT,101612,CDM,270,RC,,,,,Outpatient,,,2.9,,,,80,,2.32,percent of total billed charges,,,,85,2.47,percent of total billed charges,,,77.7,,2.25,percent of total billed charges,,,95,,2.76,percent of total billed charges,,,60,,1.74,percent of total billed charges,,1.74,2.76,
CANNULA TENDER GRIP ADULT,101612,CDM,270,RC,,,,,Inpatient,,,2.9,,,,80,,2.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.25,percent of total billed charges,,,95,,2.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.76,
KNEE BRACEw/POLYCENTRIC HINGES,101613,CDM,274,RC,L4386,HCPCS,,,Outpatient,,,141,,,,80,,112.8,percent of total billed charges,,,,85,119.85,percent of total billed charges,,,77.7,,109.56,percent of total billed charges,,,95,,133.95,percent of total billed charges,,,60,,84.6,percent of total billed charges,,84.6,133.95,
KNEE BRACEw/POLYCENTRIC HINGES,101613,CDM,274,RC,L4386,HCPCS,,,Inpatient,,,141,,,,80,,112.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,109.56,percent of total billed charges,,,95,,133.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,133.95,
LARYNGEAL AIRWAY PVC #3,101614,CDM,270,RC,,,,,Outpatient,,,27.3,,,,80,,21.84,percent of total billed charges,,,,85,23.21,percent of total billed charges,,,77.7,,21.21,percent of total billed charges,,,95,,25.94,percent of total billed charges,,,60,,16.38,percent of total billed charges,,16.38,25.94,
LARYNGEAL AIRWAY PVC #3,101614,CDM,270,RC,,,,,Inpatient,,,27.3,,,,80,,21.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,21.21,percent of total billed charges,,,95,,25.94,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,25.94,
LARYNGEAL AIRWAY PVC #5,101615,CDM,270,RC,,,,,Outpatient,,,25.9,,,,80,,20.72,percent of total billed charges,,,,85,22.02,percent of total billed charges,,,77.7,,20.12,percent of total billed charges,,,95,,24.61,percent of total billed charges,,,60,,15.54,percent of total billed charges,,15.54,24.61,
LARYNGEAL AIRWAY PVC #5,101615,CDM,270,RC,,,,,Inpatient,,,25.9,,,,80,,20.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,20.12,percent of total billed charges,,,95,,24.61,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,24.61,
SPINAL/EPIDURAL 19G TRAY (SUB),101616,CDM,270,RC,,,,,Outpatient,,,172.7,,,,80,,138.16,percent of total billed charges,,,,85,146.8,percent of total billed charges,,,77.7,,134.19,percent of total billed charges,,,95,,164.07,percent of total billed charges,,,60,,103.62,percent of total billed charges,,103.62,164.07,
SPINAL/EPIDURAL 19G TRAY (SUB),101616,CDM,270,RC,,,,,Inpatient,,,172.7,,,,80,,138.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,134.19,percent of total billed charges,,,95,,164.07,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,164.07,
FEEDING MIC-KEY BUTTON 12fr,101617,CDM,270,RC,,,,,Outpatient,,,323.8,,,,80,,259.04,percent of total billed charges,,,,85,275.23,percent of total billed charges,,,77.7,,251.59,percent of total billed charges,,,95,,307.61,percent of total billed charges,,,60,,194.28,percent of total billed charges,,194.28,307.61,
FEEDING MIC-KEY BUTTON 12fr,101617,CDM,270,RC,,,,,Inpatient,,,323.8,,,,80,,259.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,251.59,percent of total billed charges,,,95,,307.61,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,307.61,
ALEXIS O LARGE RETRACTOR,101619,CDM,270,RC,,,,,Outpatient,,,315,,,,80,,252,percent of total billed charges,,,,85,267.75,percent of total billed charges,,,77.7,,244.76,percent of total billed charges,,,95,,299.25,percent of total billed charges,,,60,,189,percent of total billed charges,,189,299.25,
ALEXIS O LARGE RETRACTOR,101619,CDM,270,RC,,,,,Inpatient,,,315,,,,80,,252,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,244.76,percent of total billed charges,,,95,,299.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,299.25,
ALEXIS O XSMALL  RETRACTOR,101620,CDM,270,RC,,,,,Outpatient,,,227.5,,,,80,,182,percent of total billed charges,,,,85,193.38,percent of total billed charges,,,77.7,,176.77,percent of total billed charges,,,95,,216.13,percent of total billed charges,,,60,,136.5,percent of total billed charges,,136.5,216.13,
ALEXIS O XSMALL  RETRACTOR,101620,CDM,270,RC,,,,,Inpatient,,,227.5,,,,80,,182,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,176.77,percent of total billed charges,,,95,,216.13,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,216.13,
MACROBORE EXT,101621,CDM,270,RC,,,,,Outpatient,,,3.2,,,,80,,2.56,percent of total billed charges,,,,85,2.72,percent of total billed charges,,,77.7,,2.49,percent of total billed charges,,,95,,3.04,percent of total billed charges,,,60,,1.92,percent of total billed charges,,1.92,3.04,
MACROBORE EXT,101621,CDM,270,RC,,,,,Inpatient,,,3.2,,,,80,,2.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.49,percent of total billed charges,,,95,,3.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.04,
RATE FLOW REGULATOR IV LINE,101623,CDM,270,RC,,,,,Outpatient,,,18.8,,,,80,,15.04,percent of total billed charges,,,,85,15.98,percent of total billed charges,,,77.7,,14.61,percent of total billed charges,,,95,,17.86,percent of total billed charges,,,60,,11.28,percent of total billed charges,,11.28,17.86,
RATE FLOW REGULATOR IV LINE,101623,CDM,270,RC,,,,,Inpatient,,,18.8,,,,80,,15.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.61,percent of total billed charges,,,95,,17.86,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.86,
NEURO PULSE LOCATOR STERILE,101624,CDM,270,RC,,,,,Outpatient,,,190.1,,,,80,,152.08,percent of total billed charges,,,,85,161.59,percent of total billed charges,,,77.7,,147.71,percent of total billed charges,,,95,,180.6,percent of total billed charges,,,60,,114.06,percent of total billed charges,,114.06,180.6,
NEURO PULSE LOCATOR STERILE,101624,CDM,270,RC,,,,,Inpatient,,,190.1,,,,80,,152.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,147.71,percent of total billed charges,,,95,,180.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,180.6,
TRACH 7.0 BLUE LINE ULTRA,101625,CDM,270,RC,,,,,Outpatient,,,117.1,,,,80,,93.68,percent of total billed charges,,,,85,99.54,percent of total billed charges,,,77.7,,90.99,percent of total billed charges,,,95,,111.25,percent of total billed charges,,,60,,70.26,percent of total billed charges,,70.26,111.25,
TRACH 7.0 BLUE LINE ULTRA,101625,CDM,270,RC,,,,,Inpatient,,,117.1,,,,80,,93.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,90.99,percent of total billed charges,,,95,,111.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,111.25,
TRACH TUBE INNER CANNULA 7.0 BLUE LINE,101626,CDM,270,RC,,,,,Outpatient,,,10.6,,,,80,,8.48,percent of total billed charges,,,,85,9.01,percent of total billed charges,,,77.7,,8.24,percent of total billed charges,,,95,,10.07,percent of total billed charges,,,60,,6.36,percent of total billed charges,,6.36,10.07,
TRACH TUBE INNER CANNULA 7.0 BLUE LINE,101626,CDM,270,RC,,,,,Inpatient,,,10.6,,,,80,,8.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.24,percent of total billed charges,,,95,,10.07,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.07,
FOLEY CATH 24FR 3OCC 3WAY,101627,CDM,270,RC,,,,,Outpatient,,,36.7,,,,80,,29.36,percent of total billed charges,,,,85,31.2,percent of total billed charges,,,77.7,,28.52,percent of total billed charges,,,95,,34.87,percent of total billed charges,,,60,,22.02,percent of total billed charges,,22.02,34.87,
FOLEY CATH 24FR 3OCC 3WAY,101627,CDM,270,RC,,,,,Inpatient,,,36.7,,,,80,,29.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,28.52,percent of total billed charges,,,95,,34.87,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,34.87,
NASAL DRUG DELIVERY DEVICE,101630,CDM,270,RC,,,,,Outpatient,,,30.8,,,,80,,24.64,percent of total billed charges,,,,85,26.18,percent of total billed charges,,,77.7,,23.93,percent of total billed charges,,,95,,29.26,percent of total billed charges,,,60,,18.48,percent of total billed charges,,18.48,29.26,
NASAL DRUG DELIVERY DEVICE,101630,CDM,270,RC,,,,,Inpatient,,,30.8,,,,80,,24.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,23.93,percent of total billed charges,,,95,,29.26,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,29.26,
PROPEL MOMETASONE FUROATE IMPLANT MINI,101631,CDM,278,RC,C2625,HCPCS,,,Outpatient,,,3657.5,,,,80,,2926,percent of total billed charges,,,,85,3108.88,percent of total billed charges,,,77.7,,2841.88,percent of total billed charges,,,95,,3474.63,percent of total billed charges,,,60,,2194.5,percent of total billed charges,,2194.5,3474.63,
PROPEL MOMETASONE FUROATE IMPLANT MINI,101631,CDM,278,RC,C2625,HCPCS,,,Inpatient,,,3657.5,,,,80,,2926,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2841.88,percent of total billed charges,,,95,,3474.63,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3474.63,
INSUFFLATION PNEUMO SURE HIGH FLOW,101632,CDM,270,RC,,,,,Outpatient,,,423.8,,,,80,,339.04,percent of total billed charges,,,,85,360.23,percent of total billed charges,,,77.7,,329.29,percent of total billed charges,,,95,,402.61,percent of total billed charges,,,60,,254.28,percent of total billed charges,,254.28,402.61,
INSUFFLATION PNEUMO SURE HIGH FLOW,101632,CDM,270,RC,,,,,Inpatient,,,423.8,,,,80,,339.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,329.29,percent of total billed charges,,,95,,402.61,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,402.61,
OPTIFOAM AG 4 X 4,101634,CDM,270,RC,,,,,Outpatient,,,22,,,,80,,17.6,percent of total billed charges,,,,85,18.7,percent of total billed charges,,,77.7,,17.09,percent of total billed charges,,,95,,20.9,percent of total billed charges,,,60,,13.2,percent of total billed charges,,13.2,20.9,
OPTIFOAM AG 4 X 4,101634,CDM,270,RC,,,,,Inpatient,,,22,,,,80,,17.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,17.09,percent of total billed charges,,,95,,20.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,20.9,
ALEXIS O X-LARGE RETRACTOR,101636,CDM,270,RC,,,,,Outpatient,,,311.5,,,,80,,249.2,percent of total billed charges,,,,85,264.78,percent of total billed charges,,,77.7,,242.04,percent of total billed charges,,,95,,295.93,percent of total billed charges,,,60,,186.9,percent of total billed charges,,186.9,295.93,
ALEXIS O X-LARGE RETRACTOR,101636,CDM,270,RC,,,,,Inpatient,,,311.5,,,,80,,249.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,242.04,percent of total billed charges,,,95,,295.93,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,295.93,
PROPEL MOMETASONE FUROATE  CONTOUR,101642,CDM,278,RC,C2625,HCPCS,,,Outpatient,,,3657.5,,,,80,,2926,percent of total billed charges,,,,85,3108.88,percent of total billed charges,,,77.7,,2841.88,percent of total billed charges,,,95,,3474.63,percent of total billed charges,,,60,,2194.5,percent of total billed charges,,2194.5,3474.63,
PROPEL MOMETASONE FUROATE  CONTOUR,101642,CDM,278,RC,C2625,HCPCS,,,Inpatient,,,3657.5,,,,80,,2926,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2841.88,percent of total billed charges,,,95,,3474.63,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3474.63,
SINUS BALLOON INFLATION DEVICE,101643,CDM,270,RC,,,,,Outpatient,,,261,,,,80,,208.8,percent of total billed charges,,,,85,221.85,percent of total billed charges,,,77.7,,202.8,percent of total billed charges,,,95,,247.95,percent of total billed charges,,,60,,156.6,percent of total billed charges,,156.6,247.95,
SINUS BALLOON INFLATION DEVICE,101643,CDM,270,RC,,,,,Inpatient,,,261,,,,80,,208.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,202.8,percent of total billed charges,,,95,,247.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,247.95,
SINUS BALLOON SPIN PLUS,101644,CDM,278,RC,C1726,HCPCS,,,Outpatient,,,6825,,,,80,,5460,percent of total billed charges,,,,85,5801.25,percent of total billed charges,,,77.7,,5303.03,percent of total billed charges,,,95,,6483.75,percent of total billed charges,,,60,,4095,percent of total billed charges,,4095,6483.75,
SINUS BALLOON SPIN PLUS,101644,CDM,278,RC,C1726,HCPCS,,,Inpatient,,,6825,,,,80,,5460,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5303.03,percent of total billed charges,,,95,,6483.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6483.75,
EPIDURAL CATH PERIFIX PF 19G X 39,101645,CDM,270,RC,,,,,Outpatient,,,31.1,,,,80,,24.88,percent of total billed charges,,,,85,26.44,percent of total billed charges,,,77.7,,24.16,percent of total billed charges,,,95,,29.55,percent of total billed charges,,,60,,18.66,percent of total billed charges,,18.66,29.55,
EPIDURAL CATH PERIFIX PF 19G X 39,101645,CDM,270,RC,,,,,Inpatient,,,31.1,,,,80,,24.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,24.16,percent of total billed charges,,,95,,29.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,29.55,
DIEGO PWRD DISSECT BLADE  3.4MM,101646,CDM,270,RC,,,,,Outpatient,,,380.7,,,,80,,304.56,percent of total billed charges,,,,85,323.6,percent of total billed charges,,,77.7,,295.8,percent of total billed charges,,,95,,361.67,percent of total billed charges,,,60,,228.42,percent of total billed charges,,228.42,361.67,
DIEGO PWRD DISSECT BLADE  3.4MM,101646,CDM,270,RC,,,,,Inpatient,,,380.7,,,,80,,304.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,295.8,percent of total billed charges,,,95,,361.67,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,361.67,
MESH VENTRALEX HERNIA PATCH LARGE BARD,101649,CDM,278,RC,C1781,HCPCS,,,Outpatient,,,1641.5,,,,80,,1313.2,percent of total billed charges,,,,85,1395.28,percent of total billed charges,,,77.7,,1275.45,percent of total billed charges,,,95,,1559.43,percent of total billed charges,,,60,,984.9,percent of total billed charges,,984.9,1559.43,
MESH VENTRALEX HERNIA PATCH LARGE BARD,101649,CDM,278,RC,C1781,HCPCS,,,Inpatient,,,1641.5,,,,80,,1313.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1275.45,percent of total billed charges,,,95,,1559.43,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1559.43,
HAND SPLINT SM RT WITH FINGER SEPERATOR,101651,CDM,270,RC,,,,,Outpatient,,,226,,,,80,,180.8,percent of total billed charges,,,,85,192.1,percent of total billed charges,,,77.7,,175.6,percent of total billed charges,,,95,,214.7,percent of total billed charges,,,60,,135.6,percent of total billed charges,,135.6,214.7,
HAND SPLINT SM RT WITH FINGER SEPERATOR,101651,CDM,270,RC,,,,,Inpatient,,,226,,,,80,,180.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,175.6,percent of total billed charges,,,95,,214.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,214.7,
FIBERWIRE 4-0 ARTHREX,101652,CDM,270,RC,,,,,Outpatient,,,1.4,,,,80,,1.12,percent of total billed charges,,,,85,1.19,percent of total billed charges,,,77.7,,1.09,percent of total billed charges,,,95,,1.33,percent of total billed charges,,,60,,0.84,percent of total billed charges,,0.84,1.33,
FIBERWIRE 4-0 ARTHREX,101652,CDM,270,RC,,,,,Inpatient,,,1.4,,,,80,,1.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.09,percent of total billed charges,,,95,,1.33,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.33,
MCGRATH MAC SIZE 4,101659,CDM,270,RC,,,,,Outpatient,,,49.2,,,,80,,39.36,percent of total billed charges,,,,85,41.82,percent of total billed charges,,,77.7,,38.23,percent of total billed charges,,,95,,46.74,percent of total billed charges,,,60,,29.52,percent of total billed charges,,29.52,46.74,
MCGRATH MAC SIZE 4,101659,CDM,270,RC,,,,,Inpatient,,,49.2,,,,80,,39.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,38.23,percent of total billed charges,,,95,,46.74,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,46.74,
MCGRATH MAC SIZE 3,101660,CDM,270,RC,,,,,Outpatient,,,49.2,,,,80,,39.36,percent of total billed charges,,,,85,41.82,percent of total billed charges,,,77.7,,38.23,percent of total billed charges,,,95,,46.74,percent of total billed charges,,,60,,29.52,percent of total billed charges,,29.52,46.74,
MCGRATH MAC SIZE 3,101660,CDM,270,RC,,,,,Inpatient,,,49.2,,,,80,,39.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,38.23,percent of total billed charges,,,95,,46.74,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,46.74,
LEAD HAND XLG STERILE,101663,CDM,270,RC,,,,,Outpatient,,,142.3,,,,80,,113.84,percent of total billed charges,,,,85,120.96,percent of total billed charges,,,77.7,,110.57,percent of total billed charges,,,95,,135.19,percent of total billed charges,,,60,,85.38,percent of total billed charges,,85.38,135.19,
LEAD HAND XLG STERILE,101663,CDM,270,RC,,,,,Inpatient,,,142.3,,,,80,,113.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,110.57,percent of total billed charges,,,95,,135.19,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,135.19,
ADAPTIC DRESSING 3X16 NON ADHESIVE,101664,CDM,270,RC,,,,,Outpatient,,,2.6,,,,80,,2.08,percent of total billed charges,,,,85,2.21,percent of total billed charges,,,77.7,,2.02,percent of total billed charges,,,95,,2.47,percent of total billed charges,,,60,,1.56,percent of total billed charges,,1.56,2.47,
ADAPTIC DRESSING 3X16 NON ADHESIVE,101664,CDM,270,RC,,,,,Inpatient,,,2.6,,,,80,,2.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.02,percent of total billed charges,,,95,,2.47,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.47,
THRESHOLD PEP,101666,CDM,270,RC,,,,,Outpatient,,,52.2,,,,80,,41.76,percent of total billed charges,,,,85,44.37,percent of total billed charges,,,77.7,,40.56,percent of total billed charges,,,95,,49.59,percent of total billed charges,,,60,,31.32,percent of total billed charges,,31.32,49.59,
THRESHOLD PEP,101666,CDM,270,RC,,,,,Inpatient,,,52.2,,,,80,,41.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,40.56,percent of total billed charges,,,95,,49.59,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,49.59,
ADJUSTABLE EXTENSION SPLINT SM RT,101669,CDM,274,RC,L3931,HCPCS,,,Outpatient,,,459.1,,,,80,,367.28,percent of total billed charges,,,,50,97.88,fee schedule,,,77.7,,356.72,percent of total billed charges,,,95,,436.15,percent of total billed charges,,,60,,275.46,percent of total billed charges,,97.88,436.15,
ADJUSTABLE EXTENSION SPLINT SM RT,101669,CDM,274,RC,L3931,HCPCS,,,Inpatient,,,459.1,,,,80,,367.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,356.72,percent of total billed charges,,,95,,436.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,436.15,
L4396 PODUS BOOT WITH AMBULATION ATTACHMENT,101670,CDM,274,RC,L4396,HCPCS,,,Outpatient,,,370,,,,80,,296,percent of total billed charges,,,,50,91.95,fee schedule,,,77.7,,287.49,percent of total billed charges,,,95,,351.5,percent of total billed charges,,,60,,222,percent of total billed charges,,91.95,351.5,
L4396 PODUS BOOT WITH AMBULATION ATTACHMENT,101670,CDM,274,RC,L4396,HCPCS,,,Inpatient,,,370,,,,80,,296,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,287.49,percent of total billed charges,,,95,,351.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,351.5,
SPINAL ANES TRAY W/O DRUGS SUB,101671,CDM,270,RC,,,,,Outpatient,,,35.1,,,,80,,28.08,percent of total billed charges,,,,85,29.84,percent of total billed charges,,,77.7,,27.27,percent of total billed charges,,,95,,33.35,percent of total billed charges,,,60,,21.06,percent of total billed charges,,21.06,33.35,
SPINAL ANES TRAY W/O DRUGS SUB,101671,CDM,270,RC,,,,,Inpatient,,,35.1,,,,80,,28.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,27.27,percent of total billed charges,,,95,,33.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,33.35,
ANTI REFLUX FILTER,101673,CDM,270,RC,,,,,Outpatient,,,20.2,,,,80,,16.16,percent of total billed charges,,,,85,17.17,percent of total billed charges,,,77.7,,15.7,percent of total billed charges,,,95,,19.19,percent of total billed charges,,,60,,12.12,percent of total billed charges,,12.12,19.19,
ANTI REFLUX FILTER,101673,CDM,270,RC,,,,,Inpatient,,,20.2,,,,80,,16.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,15.7,percent of total billed charges,,,95,,19.19,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,19.19,
VENTILATOR CIRCUIT ADULT,101676,CDM,270,RC,,,,,Outpatient,,,49.6,,,,80,,39.68,percent of total billed charges,,,,85,42.16,percent of total billed charges,,,77.7,,38.54,percent of total billed charges,,,95,,47.12,percent of total billed charges,,,60,,29.76,percent of total billed charges,,29.76,47.12,
VENTILATOR CIRCUIT ADULT,101676,CDM,270,RC,,,,,Inpatient,,,49.6,,,,80,,39.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,38.54,percent of total billed charges,,,95,,47.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,47.12,
ZZZVENTILATOR CIRCUIT PEDIATRIC,101677,CDM,270,RC,,,,,Outpatient,,,47.3,,,,80,,37.84,percent of total billed charges,,,,85,40.21,percent of total billed charges,,,77.7,,36.75,percent of total billed charges,,,95,,44.94,percent of total billed charges,,,60,,28.38,percent of total billed charges,,28.38,44.94,
ZZZVENTILATOR CIRCUIT PEDIATRIC,101677,CDM,270,RC,,,,,Inpatient,,,47.3,,,,80,,37.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,36.75,percent of total billed charges,,,95,,44.94,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,44.94,
BLADDER INJECTION NEEDLE,101683,CDM,270,RC,,,,,Outpatient,,,5.7,,,,80,,4.56,percent of total billed charges,,,,85,4.85,percent of total billed charges,,,77.7,,4.43,percent of total billed charges,,,95,,5.42,percent of total billed charges,,,60,,3.42,percent of total billed charges,,3.42,5.42,
BLADDER INJECTION NEEDLE,101683,CDM,270,RC,,,,,Inpatient,,,5.7,,,,80,,4.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.43,percent of total billed charges,,,95,,5.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.42,
CATHETER CARE WIPES,101686,CDM,270,RC,,,,,Outpatient,,,4.7,,,,80,,3.76,percent of total billed charges,,,,85,4,percent of total billed charges,,,77.7,,3.65,percent of total billed charges,,,95,,4.47,percent of total billed charges,,,60,,2.82,percent of total billed charges,,2.82,4.47,
CATHETER CARE WIPES,101686,CDM,270,RC,,,,,Inpatient,,,4.7,,,,80,,3.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.65,percent of total billed charges,,,95,,4.47,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.47,
ENDOSMARTCAP,101688,CDM,270,RC,,,,,Outpatient,,,66.5,,,,80,,53.2,percent of total billed charges,,,,85,56.53,percent of total billed charges,,,77.7,,51.67,percent of total billed charges,,,95,,63.18,percent of total billed charges,,,60,,39.9,percent of total billed charges,,39.9,63.18,
ENDOSMARTCAP,101688,CDM,270,RC,,,,,Inpatient,,,66.5,,,,80,,53.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,51.67,percent of total billed charges,,,95,,63.18,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,63.18,
OPTILOCK NON ADH 5 X 5.5,101691,CDM,270,RC,,,,,Outpatient,,,8.3,,,,80,,6.64,percent of total billed charges,,,,85,7.06,percent of total billed charges,,,77.7,,6.45,percent of total billed charges,,,95,,7.89,percent of total billed charges,,,60,,4.98,percent of total billed charges,,4.98,7.89,
OPTILOCK NON ADH 5 X 5.5,101691,CDM,270,RC,,,,,Inpatient,,,8.3,,,,80,,6.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.45,percent of total billed charges,,,95,,7.89,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.89,
OPTILOCK NON ADH 6.5 X 10,101692,CDM,270,RC,,,,,Outpatient,,,18.2,,,,80,,14.56,percent of total billed charges,,,,85,15.47,percent of total billed charges,,,77.7,,14.14,percent of total billed charges,,,95,,17.29,percent of total billed charges,,,60,,10.92,percent of total billed charges,,10.92,17.29,
OPTILOCK NON ADH 6.5 X 10,101692,CDM,270,RC,,,,,Inpatient,,,18.2,,,,80,,14.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.14,percent of total billed charges,,,95,,17.29,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.29,
"NEEDLE SPINAL STIMUPLEX 20GX4"" ULTRA 360",101694,CDM,270,RC,,,,,Outpatient,,,40.9,,,,80,,32.72,percent of total billed charges,,,,85,34.77,percent of total billed charges,,,77.7,,31.78,percent of total billed charges,,,95,,38.86,percent of total billed charges,,,60,,24.54,percent of total billed charges,,24.54,38.86,
"NEEDLE SPINAL STIMUPLEX 20GX4"" ULTRA 360",101694,CDM,270,RC,,,,,Inpatient,,,40.9,,,,80,,32.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,31.78,percent of total billed charges,,,95,,38.86,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,38.86,
CATHETER LEG BAG STRAP BARD,101695,CDM,270,RC,,,,,Outpatient,,,6.1,,,,80,,4.88,percent of total billed charges,,,,85,5.19,percent of total billed charges,,,77.7,,4.74,percent of total billed charges,,,95,,5.8,percent of total billed charges,,,60,,3.66,percent of total billed charges,,3.66,5.8,
CATHETER LEG BAG STRAP BARD,101695,CDM,270,RC,,,,,Inpatient,,,6.1,,,,80,,4.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.74,percent of total billed charges,,,95,,5.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.8,
NEOWRAP,101696,CDM,270,RC,,,,,Outpatient,,,9.7,,,,80,,7.76,percent of total billed charges,,,,85,8.25,percent of total billed charges,,,77.7,,7.54,percent of total billed charges,,,95,,9.22,percent of total billed charges,,,60,,5.82,percent of total billed charges,,5.82,9.22,
NEOWRAP,101696,CDM,270,RC,,,,,Inpatient,,,9.7,,,,80,,7.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.54,percent of total billed charges,,,95,,9.22,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.22,
ENDOTRACH TUBE 2.0 UNCUFFED,101697,CDM,270,RC,,,,,Outpatient,,,3,,,,80,,2.4,percent of total billed charges,,,,85,2.55,percent of total billed charges,,,77.7,,2.33,percent of total billed charges,,,95,,2.85,percent of total billed charges,,,60,,1.8,percent of total billed charges,,1.8,2.85,
ENDOTRACH TUBE 2.0 UNCUFFED,101697,CDM,270,RC,,,,,Inpatient,,,3,,,,80,,2.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.33,percent of total billed charges,,,95,,2.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.85,
LARYNGEAL AIRWAY PVC # 2,101699,CDM,270,RC,,,,,Outpatient,,,46.2,,,,80,,36.96,percent of total billed charges,,,,85,39.27,percent of total billed charges,,,77.7,,35.9,percent of total billed charges,,,95,,43.89,percent of total billed charges,,,60,,27.72,percent of total billed charges,,27.72,43.89,
LARYNGEAL AIRWAY PVC # 2,101699,CDM,270,RC,,,,,Inpatient,,,46.2,,,,80,,36.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,35.9,percent of total billed charges,,,95,,43.89,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,43.89,
LARYNGEAL AIRWAY PVC #2.5,101700,CDM,270,RC,,,,,Outpatient,,,27.2,,,,80,,21.76,percent of total billed charges,,,,85,23.12,percent of total billed charges,,,77.7,,21.13,percent of total billed charges,,,95,,25.84,percent of total billed charges,,,60,,16.32,percent of total billed charges,,16.32,25.84,
LARYNGEAL AIRWAY PVC #2.5,101700,CDM,270,RC,,,,,Inpatient,,,27.2,,,,80,,21.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,21.13,percent of total billed charges,,,95,,25.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,25.84,
SONICBEAT ELECTRO CUTTING COAG,101701,CDM,270,RC,,,,,Outpatient,,,1015,,,,80,,812,percent of total billed charges,,,,85,862.75,percent of total billed charges,,,77.7,,788.66,percent of total billed charges,,,95,,964.25,percent of total billed charges,,,60,,609,percent of total billed charges,,609,964.25,
SONICBEAT ELECTRO CUTTING COAG,101701,CDM,270,RC,,,,,Inpatient,,,1015,,,,80,,812,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,788.66,percent of total billed charges,,,95,,964.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,964.25,
OPTICHAMBER DIAMOND PEDIATRIC,101702,CDM,270,RC,,,,,Outpatient,,,48.8,,,,80,,39.04,percent of total billed charges,,,,85,41.48,percent of total billed charges,,,77.7,,37.92,percent of total billed charges,,,95,,46.36,percent of total billed charges,,,60,,29.28,percent of total billed charges,,29.28,46.36,
OPTICHAMBER DIAMOND PEDIATRIC,101702,CDM,270,RC,,,,,Inpatient,,,48.8,,,,80,,39.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,37.92,percent of total billed charges,,,95,,46.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,46.36,
OPTIFOAM SACRUM 9X9,101704,CDM,270,RC,,,,,Outpatient,,,6.2,,,,80,,4.96,percent of total billed charges,,,,85,5.27,percent of total billed charges,,,77.7,,4.82,percent of total billed charges,,,95,,5.89,percent of total billed charges,,,60,,3.72,percent of total billed charges,,3.72,5.89,
OPTIFOAM SACRUM 9X9,101704,CDM,270,RC,,,,,Inpatient,,,6.2,,,,80,,4.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.82,percent of total billed charges,,,95,,5.89,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.89,
VERRES NEEDLE ULTRA 120MM,101705,CDM,270,RC,,,,,Outpatient,,,56.3,,,,80,,45.04,percent of total billed charges,,,,85,47.86,percent of total billed charges,,,77.7,,43.75,percent of total billed charges,,,95,,53.49,percent of total billed charges,,,60,,33.78,percent of total billed charges,,33.78,53.49,
VERRES NEEDLE ULTRA 120MM,101705,CDM,270,RC,,,,,Inpatient,,,56.3,,,,80,,45.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,43.75,percent of total billed charges,,,95,,53.49,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,53.49,
MCGRATH XBLADE X3,101706,CDM,270,RC,,,,,Outpatient,,,116.8,,,,80,,93.44,percent of total billed charges,,,,85,99.28,percent of total billed charges,,,77.7,,90.75,percent of total billed charges,,,95,,110.96,percent of total billed charges,,,60,,70.08,percent of total billed charges,,70.08,110.96,
MCGRATH XBLADE X3,101706,CDM,270,RC,,,,,Inpatient,,,116.8,,,,80,,93.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,90.75,percent of total billed charges,,,95,,110.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,110.96,
WORD CATHETER,101707,CDM,270,RC,,,,,Outpatient,,,76.6,,,,80,,61.28,percent of total billed charges,,,,85,65.11,percent of total billed charges,,,77.7,,59.52,percent of total billed charges,,,95,,72.77,percent of total billed charges,,,60,,45.96,percent of total billed charges,,45.96,72.77,
WORD CATHETER,101707,CDM,270,RC,,,,,Inpatient,,,76.6,,,,80,,61.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,59.52,percent of total billed charges,,,95,,72.77,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,72.77,
SMOKE EVACUATION TUBE NEPTUNE,101709,CDM,270,RC,,,,,Outpatient,,,89,,,,80,,71.2,percent of total billed charges,,,,85,75.65,percent of total billed charges,,,77.7,,69.15,percent of total billed charges,,,95,,84.55,percent of total billed charges,,,60,,53.4,percent of total billed charges,,53.4,84.55,
SMOKE EVACUATION TUBE NEPTUNE,101709,CDM,270,RC,,,,,Inpatient,,,89,,,,80,,71.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,69.15,percent of total billed charges,,,95,,84.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,84.55,
LARYNGEAL AIRWAY SILICONE # 1 INFANT/NEO,101711,CDM,270,RC,,,,,Outpatient,,,27.9,,,,80,,22.32,percent of total billed charges,,,,85,23.72,percent of total billed charges,,,77.7,,21.68,percent of total billed charges,,,95,,26.51,percent of total billed charges,,,60,,16.74,percent of total billed charges,,16.74,26.51,
LARYNGEAL AIRWAY SILICONE # 1 INFANT/NEO,101711,CDM,270,RC,,,,,Inpatient,,,27.9,,,,80,,22.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,21.68,percent of total billed charges,,,95,,26.51,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,26.51,
INFU SURGE PRESSURE BAG 3000ml,101712,CDM,270,RC,,,,,Outpatient,,,51.8,,,,80,,41.44,percent of total billed charges,,,,85,44.03,percent of total billed charges,,,77.7,,40.25,percent of total billed charges,,,95,,49.21,percent of total billed charges,,,60,,31.08,percent of total billed charges,,31.08,49.21,
INFU SURGE PRESSURE BAG 3000ml,101712,CDM,270,RC,,,,,Inpatient,,,51.8,,,,80,,41.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,40.25,percent of total billed charges,,,95,,49.21,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,49.21,
"INTERDRY AG 10""X 36""",101718,CDM,270,RC,,,,,Outpatient,,,139.7,,,,80,,111.76,percent of total billed charges,,,,85,118.75,percent of total billed charges,,,77.7,,108.55,percent of total billed charges,,,95,,132.72,percent of total billed charges,,,60,,83.82,percent of total billed charges,,83.82,132.72,
"INTERDRY AG 10""X 36""",101718,CDM,270,RC,,,,,Inpatient,,,139.7,,,,80,,111.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,108.55,percent of total billed charges,,,95,,132.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,132.72,
TROCAR 5MM BLADELESS XT 150mm ETHICON,101719,CDM,270,RC,,,,,Outpatient,,,81.8,,,,80,,65.44,percent of total billed charges,,,,85,69.53,percent of total billed charges,,,77.7,,63.56,percent of total billed charges,,,95,,77.71,percent of total billed charges,,,60,,49.08,percent of total billed charges,,49.08,77.71,
TROCAR 5MM BLADELESS XT 150mm ETHICON,101719,CDM,270,RC,,,,,Inpatient,,,81.8,,,,80,,65.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,63.56,percent of total billed charges,,,95,,77.71,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.71,
SNARE ROTATABLE MEDIUM,101733,CDM,270,RC,,,,,Outpatient,,,86.4,,,,80,,69.12,percent of total billed charges,,,,85,73.44,percent of total billed charges,,,77.7,,67.13,percent of total billed charges,,,95,,82.08,percent of total billed charges,,,60,,51.84,percent of total billed charges,,51.84,82.08,
SNARE ROTATABLE MEDIUM,101733,CDM,270,RC,,,,,Inpatient,,,86.4,,,,80,,69.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,67.13,percent of total billed charges,,,95,,82.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,82.08,
UROVAC BLADDER EVACUATOR,101735,CDM,270,RC,,,,,Outpatient,,,144.9,,,,80,,115.92,percent of total billed charges,,,,85,123.17,percent of total billed charges,,,77.7,,112.59,percent of total billed charges,,,95,,137.66,percent of total billed charges,,,60,,86.94,percent of total billed charges,,86.94,137.66,
UROVAC BLADDER EVACUATOR,101735,CDM,270,RC,,,,,Inpatient,,,144.9,,,,80,,115.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,112.59,percent of total billed charges,,,95,,137.66,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,137.66,
FOLEY CATH 16FR 5 CC SILVER,101739,CDM,270,RC,,,,,Outpatient,,,26.3,,,,80,,21.04,percent of total billed charges,,,,85,22.36,percent of total billed charges,,,77.7,,20.44,percent of total billed charges,,,95,,24.99,percent of total billed charges,,,60,,15.78,percent of total billed charges,,15.78,24.99,
FOLEY CATH 16FR 5 CC SILVER,101739,CDM,270,RC,,,,,Inpatient,,,26.3,,,,80,,21.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,20.44,percent of total billed charges,,,95,,24.99,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,24.99,
FOLEY CATH 16FR 5 CC SILVER COUDE,101740,CDM,270,RC,,,,,Outpatient,,,46.8,,,,80,,37.44,percent of total billed charges,,,,85,39.78,percent of total billed charges,,,77.7,,36.36,percent of total billed charges,,,95,,44.46,percent of total billed charges,,,60,,28.08,percent of total billed charges,,28.08,44.46,
FOLEY CATH 16FR 5 CC SILVER COUDE,101740,CDM,270,RC,,,,,Inpatient,,,46.8,,,,80,,37.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,36.36,percent of total billed charges,,,95,,44.46,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,44.46,
PANDA PATIENT CIRCUIT,101746,CDM,270,RC,,,,,Outpatient,,,30.5,,,,80,,24.4,percent of total billed charges,,,,85,25.93,percent of total billed charges,,,77.7,,23.7,percent of total billed charges,,,95,,28.98,percent of total billed charges,,,60,,18.3,percent of total billed charges,,18.3,28.98,
PANDA PATIENT CIRCUIT,101746,CDM,270,RC,,,,,Inpatient,,,30.5,,,,80,,24.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,23.7,percent of total billed charges,,,95,,28.98,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,28.98,
PROBE SKIN TEMP PANDA,101750,CDM,270,RC,,,,,Outpatient,,,32,,,,80,,25.6,percent of total billed charges,,,,85,27.2,percent of total billed charges,,,77.7,,24.86,percent of total billed charges,,,95,,30.4,percent of total billed charges,,,60,,19.2,percent of total billed charges,,19.2,30.4,
PROBE SKIN TEMP PANDA,101750,CDM,270,RC,,,,,Inpatient,,,32,,,,80,,25.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,24.86,percent of total billed charges,,,95,,30.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,30.4,
FOLEY CATH 24FR 5 CC SILVER,101753,CDM,270,RC,,,,,Outpatient,,,27.2,,,,80,,21.76,percent of total billed charges,,,,85,23.12,percent of total billed charges,,,77.7,,21.13,percent of total billed charges,,,95,,25.84,percent of total billed charges,,,60,,16.32,percent of total billed charges,,16.32,25.84,
FOLEY CATH 24FR 5 CC SILVER,101753,CDM,270,RC,,,,,Inpatient,,,27.2,,,,80,,21.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,21.13,percent of total billed charges,,,95,,25.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,25.84,
ROTH NET RETRIEVER 360,101756,CDM,270,RC,,,,,Outpatient,,,363.9,,,,80,,291.12,percent of total billed charges,,,,85,309.32,percent of total billed charges,,,77.7,,282.75,percent of total billed charges,,,95,,345.71,percent of total billed charges,,,60,,218.34,percent of total billed charges,,218.34,345.71,
ROTH NET RETRIEVER 360,101756,CDM,270,RC,,,,,Inpatient,,,363.9,,,,80,,291.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,282.75,percent of total billed charges,,,95,,345.71,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,345.71,
ROTH NET PLATINUM RETRIEVER,101757,CDM,270,RC,,,,,Outpatient,,,350,,,,80,,280,percent of total billed charges,,,,85,297.5,percent of total billed charges,,,77.7,,271.95,percent of total billed charges,,,95,,332.5,percent of total billed charges,,,60,,210,percent of total billed charges,,210,332.5,
ROTH NET PLATINUM RETRIEVER,101757,CDM,270,RC,,,,,Inpatient,,,350,,,,80,,280,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,271.95,percent of total billed charges,,,95,,332.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,332.5,
BIOPSY CENTRA DISPOSABLE FORCEPS,101758,CDM,270,RC,,,,,Outpatient,,,19.1,,,,80,,15.28,percent of total billed charges,,,,85,16.24,percent of total billed charges,,,77.7,,14.84,percent of total billed charges,,,95,,18.15,percent of total billed charges,,,60,,11.46,percent of total billed charges,,11.46,18.15,
BIOPSY CENTRA DISPOSABLE FORCEPS,101758,CDM,270,RC,,,,,Inpatient,,,19.1,,,,80,,15.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.84,percent of total billed charges,,,95,,18.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,18.15,
SNARE EXACTO COLD,101759,CDM,270,RC,,,,,Outpatient,,,38.5,,,,80,,30.8,percent of total billed charges,,,,85,32.73,percent of total billed charges,,,77.7,,29.91,percent of total billed charges,,,95,,36.58,percent of total billed charges,,,60,,23.1,percent of total billed charges,,23.1,36.58,
SNARE EXACTO COLD,101759,CDM,270,RC,,,,,Inpatient,,,38.5,,,,80,,30.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,29.91,percent of total billed charges,,,95,,36.58,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,36.58,
EPIDURAL TUBING  W/O FILTER,101760,CDM,270,RC,,,,,Outpatient,,,22,,,,80,,17.6,percent of total billed charges,,,,85,18.7,percent of total billed charges,,,77.7,,17.09,percent of total billed charges,,,95,,20.9,percent of total billed charges,,,60,,13.2,percent of total billed charges,,13.2,20.9,
EPIDURAL TUBING  W/O FILTER,101760,CDM,270,RC,,,,,Inpatient,,,22,,,,80,,17.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,17.09,percent of total billed charges,,,95,,20.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,20.9,
ARTERIAL LINE KIT,101764,CDM,278,RC,C1751,HCPCS,,,Outpatient,,,279.3,,,,80,,223.44,percent of total billed charges,,,,85,237.41,percent of total billed charges,,,77.7,,217.02,percent of total billed charges,,,95,,265.34,percent of total billed charges,,,60,,167.58,percent of total billed charges,,167.58,265.34,
ARTERIAL LINE KIT,101764,CDM,278,RC,C1751,HCPCS,,,Inpatient,,,279.3,,,,80,,223.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,217.02,percent of total billed charges,,,95,,265.34,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,265.34,
PIC LINE 6FR TRIPLE LUMEN,101765,CDM,278,RC,C1751,HCPCS,,,Outpatient,,,507.5,,,,80,,406,percent of total billed charges,,,,85,431.38,percent of total billed charges,,,77.7,,394.33,percent of total billed charges,,,95,,482.13,percent of total billed charges,,,60,,304.5,percent of total billed charges,,304.5,482.13,
PIC LINE 6FR TRIPLE LUMEN,101765,CDM,278,RC,C1751,HCPCS,,,Inpatient,,,507.5,,,,80,,406,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,394.33,percent of total billed charges,,,95,,482.13,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,482.13,
TRANSPAC IV TRANSDUCER,101766,CDM,270,RC,,,,,Outpatient,,,73.4,,,,80,,58.72,percent of total billed charges,,,,85,62.39,percent of total billed charges,,,77.7,,57.03,percent of total billed charges,,,95,,69.73,percent of total billed charges,,,60,,44.04,percent of total billed charges,,44.04,69.73,
TRANSPAC IV TRANSDUCER,101766,CDM,270,RC,,,,,Inpatient,,,73.4,,,,80,,58.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,57.03,percent of total billed charges,,,95,,69.73,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,69.73,
IN-LINE SUCTION CATH TRACHE,101768,CDM,270,RC,,,,,Outpatient,,,32.6,,,,80,,26.08,percent of total billed charges,,,,85,27.71,percent of total billed charges,,,77.7,,25.33,percent of total billed charges,,,95,,30.97,percent of total billed charges,,,60,,19.56,percent of total billed charges,,19.56,30.97,
IN-LINE SUCTION CATH TRACHE,101768,CDM,270,RC,,,,,Inpatient,,,32.6,,,,80,,26.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,25.33,percent of total billed charges,,,95,,30.97,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,30.97,
FILTER HEPA  AERO-SAT STRAIGHT,101771,CDM,270,RC,,,,,Outpatient,,,15.6,,,,80,,12.48,percent of total billed charges,,,,85,13.26,percent of total billed charges,,,77.7,,12.12,percent of total billed charges,,,95,,14.82,percent of total billed charges,,,60,,9.36,percent of total billed charges,,9.36,14.82,
FILTER HEPA  AERO-SAT STRAIGHT,101771,CDM,270,RC,,,,,Inpatient,,,15.6,,,,80,,12.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.12,percent of total billed charges,,,95,,14.82,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,14.82,
IVENT CIRCUIT,101772,CDM,270,RC,,,,,Outpatient,,,186.4,,,,80,,149.12,percent of total billed charges,,,,85,158.44,percent of total billed charges,,,77.7,,144.83,percent of total billed charges,,,95,,177.08,percent of total billed charges,,,60,,111.84,percent of total billed charges,,111.84,177.08,
IVENT CIRCUIT,101772,CDM,270,RC,,,,,Inpatient,,,186.4,,,,80,,149.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,144.83,percent of total billed charges,,,95,,177.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,177.08,
PEEP VALVE,101784,CDM,270,RC,,,,,Outpatient,,,15.7,,,,80,,12.56,percent of total billed charges,,,,85,13.35,percent of total billed charges,,,77.7,,12.2,percent of total billed charges,,,95,,14.92,percent of total billed charges,,,60,,9.42,percent of total billed charges,,9.42,14.92,
PEEP VALVE,101784,CDM,270,RC,,,,,Inpatient,,,15.7,,,,80,,12.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.2,percent of total billed charges,,,95,,14.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,14.92,
ADAPTER ELBOW,101785,CDM,270,RC,,,,,Outpatient,,,1.4,,,,80,,1.12,percent of total billed charges,,,,85,1.19,percent of total billed charges,,,77.7,,1.09,percent of total billed charges,,,95,,1.33,percent of total billed charges,,,60,,0.84,percent of total billed charges,,0.84,1.33,
ADAPTER ELBOW,101785,CDM,270,RC,,,,,Inpatient,,,1.4,,,,80,,1.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.09,percent of total billed charges,,,95,,1.33,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.33,
VENTILATOR CIRCUIT NON HEATED ADULT,101786,CDM,270,RC,,,,,Outpatient,,,11.5,,,,80,,9.2,percent of total billed charges,,,,85,9.78,percent of total billed charges,,,77.7,,8.94,percent of total billed charges,,,95,,10.93,percent of total billed charges,,,60,,6.9,percent of total billed charges,,6.9,10.93,
VENTILATOR CIRCUIT NON HEATED ADULT,101786,CDM,270,RC,,,,,Inpatient,,,11.5,,,,80,,9.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.94,percent of total billed charges,,,95,,10.93,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.93,
MAIN FLOW BACTERIA FILTER (V200 FILTER),101787,CDM,270,RC,,,,,Outpatient,,,29.1,,,,80,,23.28,percent of total billed charges,,,,85,24.74,percent of total billed charges,,,77.7,,22.61,percent of total billed charges,,,95,,27.65,percent of total billed charges,,,60,,17.46,percent of total billed charges,,17.46,27.65,
MAIN FLOW BACTERIA FILTER (V200 FILTER),101787,CDM,270,RC,,,,,Inpatient,,,29.1,,,,80,,23.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,22.61,percent of total billed charges,,,95,,27.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,27.65,
FILTER HME,101790,CDM,270,RC,,,,,Outpatient,,,6.8,,,,80,,5.44,percent of total billed charges,,,,85,5.78,percent of total billed charges,,,77.7,,5.28,percent of total billed charges,,,95,,6.46,percent of total billed charges,,,60,,4.08,percent of total billed charges,,4.08,6.46,
FILTER HME,101790,CDM,270,RC,,,,,Inpatient,,,6.8,,,,80,,5.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.28,percent of total billed charges,,,95,,6.46,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.46,
FILTER HEPA GARD LIGHT PED/ADULT,101791,CDM,270,RC,,,,,Outpatient,,,9.7,,,,80,,7.76,percent of total billed charges,,,,85,8.25,percent of total billed charges,,,77.7,,7.54,percent of total billed charges,,,95,,9.22,percent of total billed charges,,,60,,5.82,percent of total billed charges,,5.82,9.22,
FILTER HEPA GARD LIGHT PED/ADULT,101791,CDM,270,RC,,,,,Inpatient,,,9.7,,,,80,,7.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.54,percent of total billed charges,,,95,,9.22,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.22,
FEEDING TUBE 12FR DOBBHOFF,101792,CDM,270,RC,,,,,Outpatient,,,39.9,,,,80,,31.92,percent of total billed charges,,,,85,33.92,percent of total billed charges,,,77.7,,31,percent of total billed charges,,,95,,37.91,percent of total billed charges,,,60,,23.94,percent of total billed charges,,23.94,37.91,
FEEDING TUBE 12FR DOBBHOFF,101792,CDM,270,RC,,,,,Inpatient,,,39.9,,,,80,,31.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,31,percent of total billed charges,,,95,,37.91,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,37.91,
FILTER HME BACTERIAL,101794,CDM,270,RC,,,,,Outpatient,,,4.6,,,,80,,3.68,percent of total billed charges,,,,85,3.91,percent of total billed charges,,,77.7,,3.57,percent of total billed charges,,,95,,4.37,percent of total billed charges,,,60,,2.76,percent of total billed charges,,2.76,4.37,
FILTER HME BACTERIAL,101794,CDM,270,RC,,,,,Inpatient,,,4.6,,,,80,,3.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.57,percent of total billed charges,,,95,,4.37,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.37,
FOLEY CATH 18FR 5 CC SILVER,101797,CDM,270,RC,,,,,Outpatient,,,23.3,,,,80,,18.64,percent of total billed charges,,,,85,19.81,percent of total billed charges,,,77.7,,18.1,percent of total billed charges,,,95,,22.14,percent of total billed charges,,,60,,13.98,percent of total billed charges,,13.98,22.14,
FOLEY CATH 18FR 5 CC SILVER,101797,CDM,270,RC,,,,,Inpatient,,,23.3,,,,80,,18.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,18.1,percent of total billed charges,,,95,,22.14,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,22.14,
FOLEY CATH 20FR 5 CC SILVER,101798,CDM,270,RC,,,,,Outpatient,,,23.3,,,,80,,18.64,percent of total billed charges,,,,85,19.81,percent of total billed charges,,,77.7,,18.1,percent of total billed charges,,,95,,22.14,percent of total billed charges,,,60,,13.98,percent of total billed charges,,13.98,22.14,
FOLEY CATH 20FR 5 CC SILVER,101798,CDM,270,RC,,,,,Inpatient,,,23.3,,,,80,,18.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,18.1,percent of total billed charges,,,95,,22.14,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,22.14,
FOLEY CATH 22FR 5 CC SILVER,101799,CDM,270,RC,,,,,Outpatient,,,23.3,,,,80,,18.64,percent of total billed charges,,,,85,19.81,percent of total billed charges,,,77.7,,18.1,percent of total billed charges,,,95,,22.14,percent of total billed charges,,,60,,13.98,percent of total billed charges,,13.98,22.14,
FOLEY CATH 22FR 5 CC SILVER,101799,CDM,270,RC,,,,,Inpatient,,,23.3,,,,80,,18.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,18.1,percent of total billed charges,,,95,,22.14,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,22.14,
SPINAL/EPIDURAL DUAL NEEDLES 25x6.5,101800,CDM,270,RC,,,,,Outpatient,,,113.4,,,,80,,90.72,percent of total billed charges,,,,85,96.39,percent of total billed charges,,,77.7,,88.11,percent of total billed charges,,,95,,107.73,percent of total billed charges,,,60,,68.04,percent of total billed charges,,68.04,107.73,
SPINAL/EPIDURAL DUAL NEEDLES 25x6.5,101800,CDM,270,RC,,,,,Inpatient,,,113.4,,,,80,,90.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,88.11,percent of total billed charges,,,95,,107.73,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,107.73,
CIRCUIT VAPOTHERM LOW FLOW,101805,CDM,270,RC,,,,,Outpatient,,,445.2,,,,80,,356.16,percent of total billed charges,,,,85,378.42,percent of total billed charges,,,77.7,,345.92,percent of total billed charges,,,95,,422.94,percent of total billed charges,,,60,,267.12,percent of total billed charges,,267.12,422.94,
CIRCUIT VAPOTHERM LOW FLOW,101805,CDM,270,RC,,,,,Inpatient,,,445.2,,,,80,,356.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,345.92,percent of total billed charges,,,95,,422.94,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,422.94,
CANNULA-VAPOTHERM ADULT,101806,CDM,270,RC,,,,,Outpatient,,,56.7,,,,80,,45.36,percent of total billed charges,,,,85,48.2,percent of total billed charges,,,77.7,,44.06,percent of total billed charges,,,95,,53.87,percent of total billed charges,,,60,,34.02,percent of total billed charges,,34.02,53.87,
CANNULA-VAPOTHERM ADULT,101806,CDM,270,RC,,,,,Inpatient,,,56.7,,,,80,,45.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,44.06,percent of total billed charges,,,95,,53.87,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,53.87,
CANNULA VAPOTHERM NEONATE,101807,CDM,270,RC,,,,,Outpatient,,,50.4,,,,80,,40.32,percent of total billed charges,,,,85,42.84,percent of total billed charges,,,77.7,,39.16,percent of total billed charges,,,95,,47.88,percent of total billed charges,,,60,,30.24,percent of total billed charges,,30.24,47.88,
CANNULA VAPOTHERM NEONATE,101807,CDM,270,RC,,,,,Inpatient,,,50.4,,,,80,,40.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,39.16,percent of total billed charges,,,95,,47.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,47.88,
CANNULA VAPOTHERM PED/ADULT,101808,CDM,270,RC,,,,,Outpatient,,,56.7,,,,80,,45.36,percent of total billed charges,,,,85,48.2,percent of total billed charges,,,77.7,,44.06,percent of total billed charges,,,95,,53.87,percent of total billed charges,,,60,,34.02,percent of total billed charges,,34.02,53.87,
CANNULA VAPOTHERM PED/ADULT,101808,CDM,270,RC,,,,,Inpatient,,,56.7,,,,80,,45.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,44.06,percent of total billed charges,,,95,,53.87,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,53.87,
LARYNGEAL AIRWAY SILICONE # 1.5,101815,CDM,270,RC,,,,,Outpatient,,,26.6,,,,80,,21.28,percent of total billed charges,,,,85,22.61,percent of total billed charges,,,77.7,,20.67,percent of total billed charges,,,95,,25.27,percent of total billed charges,,,60,,15.96,percent of total billed charges,,15.96,25.27,
LARYNGEAL AIRWAY SILICONE # 1.5,101815,CDM,270,RC,,,,,Inpatient,,,26.6,,,,80,,21.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,20.67,percent of total billed charges,,,95,,25.27,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,25.27,
SNARE  COLD 9MM,101816,CDM,270,RC,,,,,Outpatient,,,87.5,,,,80,,70,percent of total billed charges,,,,85,74.38,percent of total billed charges,,,77.7,,67.99,percent of total billed charges,,,95,,83.13,percent of total billed charges,,,60,,52.5,percent of total billed charges,,52.5,83.13,
SNARE  COLD 9MM,101816,CDM,270,RC,,,,,Inpatient,,,87.5,,,,80,,70,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,67.99,percent of total billed charges,,,95,,83.13,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,83.13,
TUBING ADAPTER .22mmX5-7mm,101817,CDM,270,RC,,,,,Outpatient,,,1.4,,,,80,,1.12,percent of total billed charges,,,,85,1.19,percent of total billed charges,,,77.7,,1.09,percent of total billed charges,,,95,,1.33,percent of total billed charges,,,60,,0.84,percent of total billed charges,,0.84,1.33,
TUBING ADAPTER .22mmX5-7mm,101817,CDM,270,RC,,,,,Inpatient,,,1.4,,,,80,,1.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.09,percent of total billed charges,,,95,,1.33,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.33,
ADAPTER CUFF UNIVERSAL,101818,CDM,270,RC,,,,,Outpatient,,,0.9,,,,80,,0.72,percent of total billed charges,,,,85,0.77,percent of total billed charges,,,77.7,,0.7,percent of total billed charges,,,95,,0.86,percent of total billed charges,,,60,,0.54,percent of total billed charges,,0.54,0.86,
ADAPTER CUFF UNIVERSAL,101818,CDM,270,RC,,,,,Inpatient,,,0.9,,,,80,,0.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.7,percent of total billed charges,,,95,,0.86,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,0.86,
ARTERIAL CATH SET,101819,CDM,278,RC,C1751,HCPCS,,,Outpatient,,,53.7,,,,80,,42.96,percent of total billed charges,,,,85,45.65,percent of total billed charges,,,77.7,,41.72,percent of total billed charges,,,95,,51.02,percent of total billed charges,,,60,,32.22,percent of total billed charges,,32.22,51.02,
ARTERIAL CATH SET,101819,CDM,278,RC,C1751,HCPCS,,,Inpatient,,,53.7,,,,80,,42.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,41.72,percent of total billed charges,,,95,,51.02,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,51.02,
SUTURE 4-0 ETHILON 1629H,101856,CDM,270,RC,,,,,Outpatient,,,6.7,,,,80,,5.36,percent of total billed charges,,,,85,5.7,percent of total billed charges,,,77.7,,5.21,percent of total billed charges,,,95,,6.37,percent of total billed charges,,,60,,4.02,percent of total billed charges,,4.02,6.37,
SUTURE 4-0 ETHILON 1629H,101856,CDM,270,RC,,,,,Inpatient,,,6.7,,,,80,,5.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.21,percent of total billed charges,,,95,,6.37,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.37,
SUTURE 3-0 CHROMIC G122H,101857,CDM,270,RC,,,,,Outpatient,,,14.3,,,,80,,11.44,percent of total billed charges,,,,85,12.16,percent of total billed charges,,,77.7,,11.11,percent of total billed charges,,,95,,13.59,percent of total billed charges,,,60,,8.58,percent of total billed charges,,8.58,13.59,
SUTURE 3-0 CHROMIC G122H,101857,CDM,270,RC,,,,,Inpatient,,,14.3,,,,80,,11.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.11,percent of total billed charges,,,95,,13.59,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.59,
SUTURE 4-0 SILK K952H,101858,CDM,270,RC,,,,,Outpatient,,,7.4,,,,80,,5.92,percent of total billed charges,,,,85,6.29,percent of total billed charges,,,77.7,,5.75,percent of total billed charges,,,95,,7.03,percent of total billed charges,,,60,,4.44,percent of total billed charges,,4.44,7.03,
SUTURE 4-0 SILK K952H,101858,CDM,270,RC,,,,,Inpatient,,,7.4,,,,80,,5.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.75,percent of total billed charges,,,95,,7.03,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.03,
SUTURE 3-0 VICRYL J916H,101859,CDM,270,RC,,,,,Outpatient,,,10.7,,,,80,,8.56,percent of total billed charges,,,,85,9.1,percent of total billed charges,,,77.7,,8.31,percent of total billed charges,,,95,,10.17,percent of total billed charges,,,60,,6.42,percent of total billed charges,,6.42,10.17,
SUTURE 3-0 VICRYL J916H,101859,CDM,270,RC,,,,,Inpatient,,,10.7,,,,80,,8.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.31,percent of total billed charges,,,95,,10.17,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.17,
SUTURE 3-0 VICRYL J423H,101860,CDM,270,RC,,,,,Outpatient,,,7.2,,,,80,,5.76,percent of total billed charges,,,,85,6.12,percent of total billed charges,,,77.7,,5.59,percent of total billed charges,,,95,,6.84,percent of total billed charges,,,60,,4.32,percent of total billed charges,,4.32,6.84,
SUTURE 3-0 VICRYL J423H,101860,CDM,270,RC,,,,,Inpatient,,,7.2,,,,80,,5.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.59,percent of total billed charges,,,95,,6.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.84,
SUTURE 4-0 ETH 1667H,101861,CDM,270,RC,,,,,Outpatient,,,11.2,,,,80,,8.96,percent of total billed charges,,,,85,9.52,percent of total billed charges,,,77.7,,8.7,percent of total billed charges,,,95,,10.64,percent of total billed charges,,,60,,6.72,percent of total billed charges,,6.72,10.64,
SUTURE 4-0 ETH 1667H,101861,CDM,270,RC,,,,,Inpatient,,,11.2,,,,80,,8.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.7,percent of total billed charges,,,95,,10.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.64,
SUTURE PROLENE 8425H,101862,CDM,270,RC,,,,,Outpatient,,,11.8,,,,80,,9.44,percent of total billed charges,,,,85,10.03,percent of total billed charges,,,77.7,,9.17,percent of total billed charges,,,95,,11.21,percent of total billed charges,,,60,,7.08,percent of total billed charges,,7.08,11.21,
SUTURE PROLENE 8425H,101862,CDM,270,RC,,,,,Inpatient,,,11.8,,,,80,,9.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.17,percent of total billed charges,,,95,,11.21,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.21,
SUTURE 4-0 PROLENE 8629H,101863,CDM,270,RC,,,,,Outpatient,,,15.9,,,,80,,12.72,percent of total billed charges,,,,85,13.52,percent of total billed charges,,,77.7,,12.35,percent of total billed charges,,,95,,15.11,percent of total billed charges,,,60,,9.54,percent of total billed charges,,9.54,15.11,
SUTURE 4-0 PROLENE 8629H,101863,CDM,270,RC,,,,,Inpatient,,,15.9,,,,80,,12.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.35,percent of total billed charges,,,95,,15.11,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.11,
SUTURE 3-0 PROLENE 8665G,101864,CDM,270,RC,,,,,Outpatient,,,13.3,,,,80,,10.64,percent of total billed charges,,,,85,11.31,percent of total billed charges,,,77.7,,10.33,percent of total billed charges,,,95,,12.64,percent of total billed charges,,,60,,7.98,percent of total billed charges,,7.98,12.64,
SUTURE 3-0 PROLENE 8665G,101864,CDM,270,RC,,,,,Inpatient,,,13.3,,,,80,,10.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.33,percent of total billed charges,,,95,,12.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,12.64,
SUTURE 6-0 PROLENE 8695G,101865,CDM,270,RC,,,,,Outpatient,,,29.1,,,,80,,23.28,percent of total billed charges,,,,85,24.74,percent of total billed charges,,,77.7,,22.61,percent of total billed charges,,,95,,27.65,percent of total billed charges,,,60,,17.46,percent of total billed charges,,17.46,27.65,
SUTURE 6-0 PROLENE 8695G,101865,CDM,270,RC,,,,,Inpatient,,,29.1,,,,80,,23.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,22.61,percent of total billed charges,,,95,,27.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,27.65,
SUTURE 2-0 MONOFILAMENT Z443H,101866,CDM,270,RC,,,,,Outpatient,,,18,,,,80,,14.4,percent of total billed charges,,,,85,15.3,percent of total billed charges,,,77.7,,13.99,percent of total billed charges,,,95,,17.1,percent of total billed charges,,,60,,10.8,percent of total billed charges,,10.8,17.1,
SUTURE 2-0 MONOFILAMENT Z443H,101866,CDM,270,RC,,,,,Inpatient,,,18,,,,80,,14.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,13.99,percent of total billed charges,,,95,,17.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.1,
SUTURE 0-SILK K834H,101867,CDM,270,RC,,,,,Outpatient,,,6,,,,80,,4.8,percent of total billed charges,,,,85,5.1,percent of total billed charges,,,77.7,,4.66,percent of total billed charges,,,95,,5.7,percent of total billed charges,,,60,,3.6,percent of total billed charges,,3.6,5.7,
SUTURE 0-SILK K834H,101867,CDM,270,RC,,,,,Inpatient,,,6,,,,80,,4.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.66,percent of total billed charges,,,95,,5.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.7,
SUTURE 0-SILK 424H,101868,CDM,270,RC,,,,,Outpatient,,,5.9,,,,80,,4.72,percent of total billed charges,,,,85,5.02,percent of total billed charges,,,77.7,,4.58,percent of total billed charges,,,95,,5.61,percent of total billed charges,,,60,,3.54,percent of total billed charges,,3.54,5.61,
SUTURE 0-SILK 424H,101868,CDM,270,RC,,,,,Inpatient,,,5.9,,,,80,,4.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.58,percent of total billed charges,,,95,,5.61,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.61,
SUTURE 4-0 PROLENE 8682G,101869,CDM,270,RC,,,,,Outpatient,,,26.9,,,,80,,21.52,percent of total billed charges,,,,85,22.87,percent of total billed charges,,,77.7,,20.9,percent of total billed charges,,,95,,25.56,percent of total billed charges,,,60,,16.14,percent of total billed charges,,16.14,25.56,
SUTURE 4-0 PROLENE 8682G,101869,CDM,270,RC,,,,,Inpatient,,,26.9,,,,80,,21.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,20.9,percent of total billed charges,,,95,,25.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,25.56,
SUTURE 5-0 PROLENE 8698G,101870,CDM,270,RC,,,,,Outpatient,,,23.5,,,,80,,18.8,percent of total billed charges,,,,85,19.98,percent of total billed charges,,,77.7,,18.26,percent of total billed charges,,,95,,22.33,percent of total billed charges,,,60,,14.1,percent of total billed charges,,14.1,22.33,
SUTURE 5-0 PROLENE 8698G,101870,CDM,270,RC,,,,,Inpatient,,,23.5,,,,80,,18.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,18.26,percent of total billed charges,,,95,,22.33,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,22.33,
SUTURE 6-0 PROLENE 8697G,101871,CDM,270,RC,,,,,Outpatient,,,28.3,,,,80,,22.64,percent of total billed charges,,,,85,24.06,percent of total billed charges,,,77.7,,21.99,percent of total billed charges,,,95,,26.89,percent of total billed charges,,,60,,16.98,percent of total billed charges,,16.98,26.89,
SUTURE 6-0 PROLENE 8697G,101871,CDM,270,RC,,,,,Inpatient,,,28.3,,,,80,,22.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,21.99,percent of total billed charges,,,95,,26.89,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,26.89,
SUTURE 4-0 PROLENE 8699G,101872,CDM,270,RC,,,,,Outpatient,,,27.1,,,,80,,21.68,percent of total billed charges,,,,85,23.04,percent of total billed charges,,,77.7,,21.06,percent of total billed charges,,,95,,25.75,percent of total billed charges,,,60,,16.26,percent of total billed charges,,16.26,25.75,
SUTURE 4-0 PROLENE 8699G,101872,CDM,270,RC,,,,,Inpatient,,,27.1,,,,80,,21.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,21.06,percent of total billed charges,,,95,,25.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,25.75,
SUTURE 5-0 ETHILON 1666G,101873,CDM,270,RC,,,,,Outpatient,,,18.9,,,,80,,15.12,percent of total billed charges,,,,85,16.07,percent of total billed charges,,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,60,,11.34,percent of total billed charges,,11.34,17.96,
SUTURE 5-0 ETHILON 1666G,101873,CDM,270,RC,,,,,Inpatient,,,18.9,,,,80,,15.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.96,
SUTURE 4-0 VICRYL J441H,101874,CDM,270,RC,,,,,Outpatient,,,9.9,,,,80,,7.92,percent of total billed charges,,,,85,8.42,percent of total billed charges,,,77.7,,7.69,percent of total billed charges,,,95,,9.41,percent of total billed charges,,,60,,5.94,percent of total billed charges,,5.94,9.41,
SUTURE 4-0 VICRYL J441H,101874,CDM,270,RC,,,,,Inpatient,,,9.9,,,,80,,7.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.69,percent of total billed charges,,,95,,9.41,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.41,
FILTER PB980 PED/ADULT,101875,CDM,270,RC,,,,,Outpatient,,,51.4,,,,80,,41.12,percent of total billed charges,,,,85,43.69,percent of total billed charges,,,77.7,,39.94,percent of total billed charges,,,95,,48.83,percent of total billed charges,,,60,,30.84,percent of total billed charges,,30.84,48.83,
FILTER PB980 PED/ADULT,101875,CDM,270,RC,,,,,Inpatient,,,51.4,,,,80,,41.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,39.94,percent of total billed charges,,,95,,48.83,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,48.83,
SUTURE 0-VICRYL PLUS J376H OR,101876,CDM,270,RC,,,,,Outpatient,,,8.7,,,,80,,6.96,percent of total billed charges,,,,85,7.4,percent of total billed charges,,,77.7,,6.76,percent of total billed charges,,,95,,8.27,percent of total billed charges,,,60,,5.22,percent of total billed charges,,5.22,8.27,
SUTURE 0-VICRYL PLUS J376H OR,101876,CDM,270,RC,,,,,Inpatient,,,8.7,,,,80,,6.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.76,percent of total billed charges,,,95,,8.27,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,8.27,
SUTURE 2-0 VICRYL J417H,101877,CDM,270,RC,,,,,Outpatient,,,7.1,,,,80,,5.68,percent of total billed charges,,,,85,6.04,percent of total billed charges,,,77.7,,5.52,percent of total billed charges,,,95,,6.75,percent of total billed charges,,,60,,4.26,percent of total billed charges,,4.26,6.75,
SUTURE 2-0 VICRYL J417H,101877,CDM,270,RC,,,,,Inpatient,,,7.1,,,,80,,5.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.52,percent of total billed charges,,,95,,6.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.75,
SUTURE 4-0 VICRYL J496G OR,101878,CDM,270,RC,,,,,Outpatient,,,20,,,,80,,16,percent of total billed charges,,,,85,17,percent of total billed charges,,,77.7,,15.54,percent of total billed charges,,,95,,19,percent of total billed charges,,,60,,12,percent of total billed charges,,12,19,
SUTURE 4-0 VICRYL J496G OR,101878,CDM,270,RC,,,,,Inpatient,,,20,,,,80,,16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,15.54,percent of total billed charges,,,95,,19,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,19,
SUTURE 4-0 CHROMIC 1654G OR,101879,CDM,270,RC,,,,,Outpatient,,,28.2,,,,80,,22.56,percent of total billed charges,,,,85,23.97,percent of total billed charges,,,77.7,,21.91,percent of total billed charges,,,95,,26.79,percent of total billed charges,,,60,,16.92,percent of total billed charges,,16.92,26.79,
SUTURE 4-0 CHROMIC 1654G OR,101879,CDM,270,RC,,,,,Inpatient,,,28.2,,,,80,,22.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,21.91,percent of total billed charges,,,95,,26.79,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,26.79,
SUTURE 2-0 SILK 583H OR,101880,CDM,270,RC,,,,,Outpatient,,,9.8,,,,80,,7.84,percent of total billed charges,,,,85,8.33,percent of total billed charges,,,77.7,,7.61,percent of total billed charges,,,95,,9.31,percent of total billed charges,,,60,,5.88,percent of total billed charges,,5.88,9.31,
SUTURE 2-0 SILK 583H OR,101880,CDM,270,RC,,,,,Inpatient,,,9.8,,,,80,,7.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.61,percent of total billed charges,,,95,,9.31,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.31,
SUTURE 3-0 PROLENE 8687H OR,101881,CDM,270,RC,,,,,Outpatient,,,16.1,,,,80,,12.88,percent of total billed charges,,,,85,13.69,percent of total billed charges,,,77.7,,12.51,percent of total billed charges,,,95,,15.3,percent of total billed charges,,,60,,9.66,percent of total billed charges,,9.66,15.3,
SUTURE 3-0 PROLENE 8687H OR,101881,CDM,270,RC,,,,,Inpatient,,,16.1,,,,80,,12.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.51,percent of total billed charges,,,95,,15.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.3,
SUTURE 3-0 VICRYL J416H OR,101882,CDM,270,RC,,,,,Outpatient,,,5,,,,80,,4,percent of total billed charges,,,,85,4.25,percent of total billed charges,,,77.7,,3.89,percent of total billed charges,,,95,,4.75,percent of total billed charges,,,60,,3,percent of total billed charges,,3,4.75,
SUTURE 3-0 VICRYL J416H OR,101882,CDM,270,RC,,,,,Inpatient,,,5,,,,80,,4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.89,percent of total billed charges,,,95,,4.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.75,
SUTURE 3-0 ETHILON 1669H OR,101883,CDM,270,RC,,,,,Outpatient,,,11.4,,,,80,,9.12,percent of total billed charges,,,,85,9.69,percent of total billed charges,,,77.7,,8.86,percent of total billed charges,,,95,,10.83,percent of total billed charges,,,60,,6.84,percent of total billed charges,,6.84,10.83,
SUTURE 3-0 ETHILON 1669H OR,101883,CDM,270,RC,,,,,Inpatient,,,11.4,,,,80,,9.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.86,percent of total billed charges,,,95,,10.83,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.83,
SUTURE 4-0 ETHILON 662G OR,101884,CDM,270,RC,,,,,Outpatient,,,5.4,,,,80,,4.32,percent of total billed charges,,,,85,4.59,percent of total billed charges,,,77.7,,4.2,percent of total billed charges,,,95,,5.13,percent of total billed charges,,,60,,3.24,percent of total billed charges,,3.24,5.13,
SUTURE 4-0 ETHILON 662G OR,101884,CDM,270,RC,,,,,Inpatient,,,5.4,,,,80,,4.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.2,percent of total billed charges,,,95,,5.13,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.13,
SUTURE 5-0 ETHILON 661G OR,101885,CDM,270,RC,,,,,Outpatient,,,6,,,,80,,4.8,percent of total billed charges,,,,85,5.1,percent of total billed charges,,,77.7,,4.66,percent of total billed charges,,,95,,5.7,percent of total billed charges,,,60,,3.6,percent of total billed charges,,3.6,5.7,
SUTURE 5-0 ETHILON 661G OR,101885,CDM,270,RC,,,,,Inpatient,,,6,,,,80,,4.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.66,percent of total billed charges,,,95,,5.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.7,
SUTURE 5-0 PROLENE 8661G OR,101886,CDM,270,RC,,,,,Outpatient,,,13.5,,,,80,,10.8,percent of total billed charges,,,,85,11.48,percent of total billed charges,,,77.7,,10.49,percent of total billed charges,,,95,,12.83,percent of total billed charges,,,60,,8.1,percent of total billed charges,,8.1,12.83,
SUTURE 5-0 PROLENE 8661G OR,101886,CDM,270,RC,,,,,Inpatient,,,13.5,,,,80,,10.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.49,percent of total billed charges,,,95,,12.83,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,12.83,
SUTURE PERMAHAND SILK LA54G OR,101887,CDM,270,RC,,,,,Outpatient,,,7.8,,,,80,,6.24,percent of total billed charges,,,,85,6.63,percent of total billed charges,,,77.7,,6.06,percent of total billed charges,,,95,,7.41,percent of total billed charges,,,60,,4.68,percent of total billed charges,,4.68,7.41,
SUTURE PERMAHAND SILK LA54G OR,101887,CDM,270,RC,,,,,Inpatient,,,7.8,,,,80,,6.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.06,percent of total billed charges,,,95,,7.41,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.41,
SUTURE 4-0 VICRYL J415H OR,101888,CDM,270,RC,,,,,Outpatient,,,7.3,,,,80,,5.84,percent of total billed charges,,,,85,6.21,percent of total billed charges,,,77.7,,5.67,percent of total billed charges,,,95,,6.94,percent of total billed charges,,,60,,4.38,percent of total billed charges,,4.38,6.94,
SUTURE 4-0 VICRYL J415H OR,101888,CDM,270,RC,,,,,Inpatient,,,7.3,,,,80,,5.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.67,percent of total billed charges,,,95,,6.94,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.94,
SUTURE 2-0 ETHILON 585H OR,101889,CDM,270,RC,,,,,Outpatient,,,17.9,,,,80,,14.32,percent of total billed charges,,,,85,15.22,percent of total billed charges,,,77.7,,13.91,percent of total billed charges,,,95,,17.01,percent of total billed charges,,,60,,10.74,percent of total billed charges,,10.74,17.01,
SUTURE 2-0 ETHILON 585H OR,101889,CDM,270,RC,,,,,Inpatient,,,17.9,,,,80,,14.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,13.91,percent of total billed charges,,,95,,17.01,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.01,
SUTURE 2-0 VICRYL J917H,101890,CDM,270,RC,,,,,Outpatient,,,11.2,,,,80,,8.96,percent of total billed charges,,,,85,9.52,percent of total billed charges,,,77.7,,8.7,percent of total billed charges,,,95,,10.64,percent of total billed charges,,,60,,6.72,percent of total billed charges,,6.72,10.64,
SUTURE 2-0 VICRYL J917H,101890,CDM,270,RC,,,,,Inpatient,,,11.2,,,,80,,8.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.7,percent of total billed charges,,,95,,10.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.64,
CIRCUIT DUAL LIMB HEATED ADULT/PED,101891,CDM,270,RC,,,,,Outpatient,,,182.8,,,,80,,146.24,percent of total billed charges,,,,85,155.38,percent of total billed charges,,,77.7,,142.04,percent of total billed charges,,,95,,173.66,percent of total billed charges,,,60,,109.68,percent of total billed charges,,109.68,173.66,
CIRCUIT DUAL LIMB HEATED ADULT/PED,101891,CDM,270,RC,,,,,Inpatient,,,182.8,,,,80,,146.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,142.04,percent of total billed charges,,,95,,173.66,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,173.66,
CHAMBER ADULT/PED 290ML AUTO FILL W/VENT,101892,CDM,270,RC,,,,,Outpatient,,,39.7,,,,80,,31.76,percent of total billed charges,,,,85,33.75,percent of total billed charges,,,77.7,,30.85,percent of total billed charges,,,95,,37.72,percent of total billed charges,,,60,,23.82,percent of total billed charges,,23.82,37.72,
CHAMBER ADULT/PED 290ML AUTO FILL W/VENT,101892,CDM,270,RC,,,,,Inpatient,,,39.7,,,,80,,31.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,30.85,percent of total billed charges,,,95,,37.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,37.72,
SUTURE 3-0 SILK 1679H OR,101893,CDM,270,RC,,,,,Outpatient,,,9.9,,,,80,,7.92,percent of total billed charges,,,,85,8.42,percent of total billed charges,,,77.7,,7.69,percent of total billed charges,,,95,,9.41,percent of total billed charges,,,60,,5.94,percent of total billed charges,,5.94,9.41,
SUTURE 3-0 SILK 1679H OR,101893,CDM,270,RC,,,,,Inpatient,,,9.9,,,,80,,7.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.69,percent of total billed charges,,,95,,9.41,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.41,
SUTURE 6-0 ETHILON 1698G OR,101894,CDM,270,RC,,,,,Outpatient,,,17.5,,,,80,,14,percent of total billed charges,,,,85,14.88,percent of total billed charges,,,77.7,,13.6,percent of total billed charges,,,95,,16.63,percent of total billed charges,,,60,,10.5,percent of total billed charges,,10.5,16.63,
SUTURE 6-0 ETHILON 1698G OR,101894,CDM,270,RC,,,,,Inpatient,,,17.5,,,,80,,14,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,13.6,percent of total billed charges,,,95,,16.63,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,16.63,
SUTURE 0 SILK 678G OR,101895,CDM,270,RC,,,,,Outpatient,,,4.9,,,,80,,3.92,percent of total billed charges,,,,85,4.17,percent of total billed charges,,,77.7,,3.81,percent of total billed charges,,,95,,4.66,percent of total billed charges,,,60,,2.94,percent of total billed charges,,2.94,4.66,
SUTURE 0 SILK 678G OR,101895,CDM,270,RC,,,,,Inpatient,,,4.9,,,,80,,3.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.81,percent of total billed charges,,,95,,4.66,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.66,
SUTURE 0-SILK C041D OR,101896,CDM,270,RC,,,,,Outpatient,,,49.2,,,,80,,39.36,percent of total billed charges,,,,85,41.82,percent of total billed charges,,,77.7,,38.23,percent of total billed charges,,,95,,46.74,percent of total billed charges,,,60,,29.52,percent of total billed charges,,29.52,46.74,
SUTURE 0-SILK C041D OR,101896,CDM,270,RC,,,,,Inpatient,,,49.2,,,,80,,39.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,38.23,percent of total billed charges,,,95,,46.74,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,46.74,
SUTURE 2-0 CHROMIC GL31G OR,101897,CDM,270,RC,,,,,Outpatient,,,31.9,,,,80,,25.52,percent of total billed charges,,,,85,27.12,percent of total billed charges,,,77.7,,24.79,percent of total billed charges,,,95,,30.31,percent of total billed charges,,,60,,19.14,percent of total billed charges,,19.14,30.31,
SUTURE 2-0 CHROMIC GL31G OR,101897,CDM,270,RC,,,,,Inpatient,,,31.9,,,,80,,25.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,24.79,percent of total billed charges,,,95,,30.31,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,30.31,
SUTURE 0 VICRYL J340H OR,101898,CDM,270,RC,,,,,Outpatient,,,7.2,,,,80,,5.76,percent of total billed charges,,,,85,6.12,percent of total billed charges,,,77.7,,5.59,percent of total billed charges,,,95,,6.84,percent of total billed charges,,,60,,4.32,percent of total billed charges,,4.32,6.84,
SUTURE 0 VICRYL J340H OR,101898,CDM,270,RC,,,,,Inpatient,,,7.2,,,,80,,5.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.59,percent of total billed charges,,,95,,6.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.84,
SUTURE 4-0 VICRYL J662H OR,101899,CDM,270,RC,,,,,Outpatient,,,0.5,,,,80,,0.4,percent of total billed charges,,,,85,0.43,percent of total billed charges,,,77.7,,0.39,percent of total billed charges,,,95,,0.48,percent of total billed charges,,,60,,0.3,percent of total billed charges,,0.3,0.48,
SUTURE 4-0 VICRYL J662H OR,101899,CDM,270,RC,,,,,Inpatient,,,0.5,,,,80,,0.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.39,percent of total billed charges,,,95,,0.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,0.48,
SUTURE 3-0 PLAIN GUT N862H OR,101901,CDM,270,RC,,,,,Outpatient,,,14.3,,,,80,,11.44,percent of total billed charges,,,,85,12.16,percent of total billed charges,,,77.7,,11.11,percent of total billed charges,,,95,,13.59,percent of total billed charges,,,60,,8.58,percent of total billed charges,,8.58,13.59,
SUTURE 3-0 PLAIN GUT N862H OR,101901,CDM,270,RC,,,,,Inpatient,,,14.3,,,,80,,11.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.11,percent of total billed charges,,,95,,13.59,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.59,
SUTURE 2-0 CHROMIC S113H OR,101902,CDM,270,RC,,,,,Outpatient,,,14.4,,,,80,,11.52,percent of total billed charges,,,,85,12.24,percent of total billed charges,,,77.7,,11.19,percent of total billed charges,,,95,,13.68,percent of total billed charges,,,60,,8.64,percent of total billed charges,,8.64,13.68,
SUTURE 2-0 CHROMIC S113H OR,101902,CDM,270,RC,,,,,Inpatient,,,14.4,,,,80,,11.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.19,percent of total billed charges,,,95,,13.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.68,
SUTURE 2-0 VICRYL VCP333H OR,101903,CDM,270,RC,,,,,Outpatient,,,8.3,,,,80,,6.64,percent of total billed charges,,,,85,7.06,percent of total billed charges,,,77.7,,6.45,percent of total billed charges,,,95,,7.89,percent of total billed charges,,,60,,4.98,percent of total billed charges,,4.98,7.89,
SUTURE 2-0 VICRYL VCP333H OR,101903,CDM,270,RC,,,,,Inpatient,,,8.3,,,,80,,6.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.45,percent of total billed charges,,,95,,7.89,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.89,
SUTURE 0 VICRYL PL VCP978H OR,101904,CDM,270,RC,,,,,Outpatient,,,9.1,,,,80,,7.28,percent of total billed charges,,,,85,7.74,percent of total billed charges,,,77.7,,7.07,percent of total billed charges,,,95,,8.65,percent of total billed charges,,,60,,5.46,percent of total billed charges,,5.46,8.65,
SUTURE 0 VICRYL PL VCP978H OR,101904,CDM,270,RC,,,,,Inpatient,,,9.1,,,,80,,7.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.07,percent of total billed charges,,,95,,8.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,8.65,
SUTURE O ETHIBOND X424H OR,101905,CDM,270,RC,,,,,Outpatient,,,7.7,,,,80,,6.16,percent of total billed charges,,,,85,6.55,percent of total billed charges,,,77.7,,5.98,percent of total billed charges,,,95,,7.32,percent of total billed charges,,,60,,4.62,percent of total billed charges,,4.62,7.32,
SUTURE O ETHIBOND X424H OR,101905,CDM,270,RC,,,,,Inpatient,,,7.7,,,,80,,6.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.98,percent of total billed charges,,,95,,7.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.32,
SUTURE 4-0 MONOCRYL Y214H OR,101906,CDM,270,RC,,,,,Outpatient,,,10.2,,,,80,,8.16,percent of total billed charges,,,,85,8.67,percent of total billed charges,,,77.7,,7.93,percent of total billed charges,,,95,,9.69,percent of total billed charges,,,60,,6.12,percent of total billed charges,,6.12,9.69,
SUTURE 4-0 MONOCRYL Y214H OR,101906,CDM,270,RC,,,,,Inpatient,,,10.2,,,,80,,8.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.93,percent of total billed charges,,,95,,9.69,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.69,
SUTURE 5-0 MONOCRYL Y493G OR,101907,CDM,270,RC,,,,,Outpatient,,,29,,,,80,,23.2,percent of total billed charges,,,,85,24.65,percent of total billed charges,,,77.7,,22.53,percent of total billed charges,,,95,,27.55,percent of total billed charges,,,60,,17.4,percent of total billed charges,,17.4,27.55,
SUTURE 5-0 MONOCRYL Y493G OR,101907,CDM,270,RC,,,,,Inpatient,,,29,,,,80,,23.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,22.53,percent of total billed charges,,,95,,27.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,27.55,
SUTURE 4-0 MONOCRYL Y496G OR,101908,CDM,270,RC,,,,,Outpatient,,,25.8,,,,80,,20.64,percent of total billed charges,,,,85,21.93,percent of total billed charges,,,77.7,,20.05,percent of total billed charges,,,95,,24.51,percent of total billed charges,,,60,,15.48,percent of total billed charges,,15.48,24.51,
SUTURE 4-0 MONOCRYL Y496G OR,101908,CDM,270,RC,,,,,Inpatient,,,25.8,,,,80,,20.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,20.05,percent of total billed charges,,,95,,24.51,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,24.51,
SUTURE 3-0 CHROMIC 1638H OR,101909,CDM,270,RC,,,,,Outpatient,,,27.8,,,,80,,22.24,percent of total billed charges,,,,85,23.63,percent of total billed charges,,,77.7,,21.6,percent of total billed charges,,,95,,26.41,percent of total billed charges,,,60,,16.68,percent of total billed charges,,16.68,26.41,
SUTURE 3-0 CHROMIC 1638H OR,101909,CDM,270,RC,,,,,Inpatient,,,27.8,,,,80,,22.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,21.6,percent of total billed charges,,,95,,26.41,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,26.41,
SUTURE 3-0 ETHILON 1663G OR,101910,CDM,270,RC,,,,,Outpatient,,,20.3,,,,80,,16.24,percent of total billed charges,,,,85,17.26,percent of total billed charges,,,77.7,,15.77,percent of total billed charges,,,95,,19.29,percent of total billed charges,,,60,,12.18,percent of total billed charges,,12.18,19.29,
SUTURE 3-0 ETHILON 1663G OR,101910,CDM,270,RC,,,,,Inpatient,,,20.3,,,,80,,16.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,15.77,percent of total billed charges,,,95,,19.29,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,19.29,
SUTURE 2-0 PDSII Z997G OR,101912,CDM,270,RC,,,,,Outpatient,,,84.4,,,,80,,67.52,percent of total billed charges,,,,85,71.74,percent of total billed charges,,,77.7,,65.58,percent of total billed charges,,,95,,80.18,percent of total billed charges,,,60,,50.64,percent of total billed charges,,50.64,80.18,
SUTURE 2-0 PDSII Z997G OR,101912,CDM,270,RC,,,,,Inpatient,,,84.4,,,,80,,67.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,65.58,percent of total billed charges,,,95,,80.18,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,80.18,
SUTURE 3-0 ETHILON 1993G OR,101913,CDM,270,RC,,,,,Outpatient,,,20.4,,,,80,,16.32,percent of total billed charges,,,,85,17.34,percent of total billed charges,,,77.7,,15.85,percent of total billed charges,,,95,,19.38,percent of total billed charges,,,60,,12.24,percent of total billed charges,,12.24,19.38,
SUTURE 3-0 ETHILON 1993G OR,101913,CDM,270,RC,,,,,Inpatient,,,20.4,,,,80,,16.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,15.85,percent of total billed charges,,,95,,19.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,19.38,
SUTURE 3-0 ETHILON 669H OR,101916,CDM,270,RC,,,,,Outpatient,,,9.1,,,,80,,7.28,percent of total billed charges,,,,85,7.74,percent of total billed charges,,,77.7,,7.07,percent of total billed charges,,,95,,8.65,percent of total billed charges,,,60,,5.46,percent of total billed charges,,5.46,8.65,
SUTURE 3-0 ETHILON 669H OR,101916,CDM,270,RC,,,,,Inpatient,,,9.1,,,,80,,7.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.07,percent of total billed charges,,,95,,8.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,8.65,
SUTURE 0-PROLENE 8424H OR,101918,CDM,270,RC,,,,,Outpatient,,,11.9,,,,80,,9.52,percent of total billed charges,,,,85,10.12,percent of total billed charges,,,77.7,,9.25,percent of total billed charges,,,95,,11.31,percent of total billed charges,,,60,,7.14,percent of total billed charges,,7.14,11.31,
SUTURE 0-PROLENE 8424H OR,101918,CDM,270,RC,,,,,Inpatient,,,11.9,,,,80,,9.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.25,percent of total billed charges,,,95,,11.31,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.31,
SUTURE 2-0 PROLENE 8523H OR,101919,CDM,270,RC,,,,,Outpatient,,,27.5,,,,80,,22,percent of total billed charges,,,,85,23.38,percent of total billed charges,,,77.7,,21.37,percent of total billed charges,,,95,,26.13,percent of total billed charges,,,60,,16.5,percent of total billed charges,,16.5,26.13,
SUTURE 2-0 PROLENE 8523H OR,101919,CDM,270,RC,,,,,Inpatient,,,27.5,,,,80,,22,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,21.37,percent of total billed charges,,,95,,26.13,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,26.13,
SUTURE 2-0 CHROMIC 983H OR,101920,CDM,270,RC,,,,,Outpatient,,,30,,,,80,,24,percent of total billed charges,,,,85,25.5,percent of total billed charges,,,77.7,,23.31,percent of total billed charges,,,95,,28.5,percent of total billed charges,,,60,,18,percent of total billed charges,,18,28.5,
SUTURE 2-0 CHROMIC 983H OR,101920,CDM,270,RC,,,,,Inpatient,,,30,,,,80,,24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,23.31,percent of total billed charges,,,95,,28.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,28.5,
SUTURE 2-0 SILK C016D OR,101921,CDM,270,RC,,,,,Outpatient,,,46.6,,,,80,,37.28,percent of total billed charges,,,,85,39.61,percent of total billed charges,,,77.7,,36.21,percent of total billed charges,,,95,,44.27,percent of total billed charges,,,60,,27.96,percent of total billed charges,,27.96,44.27,
SUTURE 2-0 SILK C016D OR,101921,CDM,270,RC,,,,,Inpatient,,,46.6,,,,80,,37.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,36.21,percent of total billed charges,,,95,,44.27,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,44.27,
SUTURE 3-0 VICRYL J338H OR,101922,CDM,270,RC,,,,,Outpatient,,,7.1,,,,80,,5.68,percent of total billed charges,,,,85,6.04,percent of total billed charges,,,77.7,,5.52,percent of total billed charges,,,95,,6.75,percent of total billed charges,,,60,,4.26,percent of total billed charges,,4.26,6.75,
SUTURE 3-0 VICRYL J338H OR,101922,CDM,270,RC,,,,,Inpatient,,,7.1,,,,80,,5.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.52,percent of total billed charges,,,95,,6.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.75,
SUTURE 1 VICRYL J702D OR,101923,CDM,270,RC,,,,,Outpatient,,,70.5,,,,80,,56.4,percent of total billed charges,,,,85,59.93,percent of total billed charges,,,77.7,,54.78,percent of total billed charges,,,95,,66.98,percent of total billed charges,,,60,,42.3,percent of total billed charges,,42.3,66.98,
SUTURE 1 VICRYL J702D OR,101923,CDM,270,RC,,,,,Inpatient,,,70.5,,,,80,,56.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,54.78,percent of total billed charges,,,95,,66.98,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,66.98,
SUTURE 2-0 VICRYL J775D OR,101924,CDM,270,RC,,,,,Outpatient,,,51.6,,,,80,,41.28,percent of total billed charges,,,,85,43.86,percent of total billed charges,,,77.7,,40.09,percent of total billed charges,,,95,,49.02,percent of total billed charges,,,60,,30.96,percent of total billed charges,,30.96,49.02,
SUTURE 2-0 VICRYL J775D OR,101924,CDM,270,RC,,,,,Inpatient,,,51.6,,,,80,,41.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,40.09,percent of total billed charges,,,95,,49.02,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,49.02,
SUTURE 3-0 VICRYL J838D OR,101925,CDM,270,RC,,,,,Outpatient,,,53.4,,,,80,,42.72,percent of total billed charges,,,,85,45.39,percent of total billed charges,,,77.7,,41.49,percent of total billed charges,,,95,,50.73,percent of total billed charges,,,60,,32.04,percent of total billed charges,,32.04,50.73,
SUTURE 3-0 VICRYL J838D OR,101925,CDM,270,RC,,,,,Inpatient,,,53.4,,,,80,,42.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,41.49,percent of total billed charges,,,95,,50.73,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,50.73,
SUTURE 2-0 VICRYL J839D OR,101926,CDM,270,RC,,,,,Outpatient,,,52.3,,,,80,,41.84,percent of total billed charges,,,,85,44.46,percent of total billed charges,,,77.7,,40.64,percent of total billed charges,,,95,,49.69,percent of total billed charges,,,60,,31.38,percent of total billed charges,,31.38,49.69,
SUTURE 2-0 VICRYL J839D OR,101926,CDM,270,RC,,,,,Inpatient,,,52.3,,,,80,,41.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,40.64,percent of total billed charges,,,95,,49.69,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,49.69,
SUTURE 3-0 VICRYL J864D OR,101927,CDM,270,RC,,,,,Outpatient,,,53.9,,,,80,,43.12,percent of total billed charges,,,,85,45.82,percent of total billed charges,,,77.7,,41.88,percent of total billed charges,,,95,,51.21,percent of total billed charges,,,60,,32.34,percent of total billed charges,,32.34,51.21,
SUTURE 3-0 VICRYL J864D OR,101927,CDM,270,RC,,,,,Inpatient,,,53.9,,,,80,,43.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,41.88,percent of total billed charges,,,95,,51.21,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,51.21,
SUTURE 2-0 VICRYL J957H OR,101928,CDM,270,RC,,,,,Outpatient,,,7.7,,,,80,,6.16,percent of total billed charges,,,,85,6.55,percent of total billed charges,,,77.7,,5.98,percent of total billed charges,,,95,,7.32,percent of total billed charges,,,60,,4.62,percent of total billed charges,,4.62,7.32,
SUTURE 2-0 VICRYL J957H OR,101928,CDM,270,RC,,,,,Inpatient,,,7.7,,,,80,,6.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.98,percent of total billed charges,,,95,,7.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.32,
SUTURE 4-0 MONOCRYL Y682H OR,101929,CDM,270,RC,,,,,Outpatient,,,9.8,,,,80,,7.84,percent of total billed charges,,,,85,8.33,percent of total billed charges,,,77.7,,7.61,percent of total billed charges,,,95,,9.31,percent of total billed charges,,,60,,5.88,percent of total billed charges,,5.88,9.31,
SUTURE 4-0 MONOCRYL Y682H OR,101929,CDM,270,RC,,,,,Inpatient,,,9.8,,,,80,,7.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.61,percent of total billed charges,,,95,,9.31,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.31,
FINGER SPLINT FROG PADDED LG,101937,CDM,270,RC,,,,,Outpatient,,,2.8,,,,80,,2.24,percent of total billed charges,,,,85,2.38,percent of total billed charges,,,77.7,,2.18,percent of total billed charges,,,95,,2.66,percent of total billed charges,,,60,,1.68,percent of total billed charges,,1.68,2.66,
FINGER SPLINT FROG PADDED LG,101937,CDM,270,RC,,,,,Inpatient,,,2.8,,,,80,,2.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.18,percent of total billed charges,,,95,,2.66,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.66,
FINGER SPLINT FROG PADDED SMALL,101938,CDM,270,RC,,,,,Outpatient,,,3.8,,,,80,,3.04,percent of total billed charges,,,,85,3.23,percent of total billed charges,,,77.7,,2.95,percent of total billed charges,,,95,,3.61,percent of total billed charges,,,60,,2.28,percent of total billed charges,,2.28,3.61,
FINGER SPLINT FROG PADDED SMALL,101938,CDM,270,RC,,,,,Inpatient,,,3.8,,,,80,,3.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.95,percent of total billed charges,,,95,,3.61,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.61,
FINGER COT MEDIUM,101939,CDM,270,RC,,,,,Outpatient,,,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
FINGER COT MEDIUM,101939,CDM,270,RC,,,,,Inpatient,,,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
FINGER COT LARGE,101940,CDM,270,RC,,,,,Outpatient,,,4.6,,,,80,,3.68,percent of total billed charges,,,,85,3.91,percent of total billed charges,,,77.7,,3.57,percent of total billed charges,,,95,,4.37,percent of total billed charges,,,60,,2.76,percent of total billed charges,,2.76,4.37,
FINGER COT LARGE,101940,CDM,270,RC,,,,,Inpatient,,,4.6,,,,80,,3.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.57,percent of total billed charges,,,95,,4.37,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.37,
"FINGER CURVED PADDED 6""",101941,CDM,270,RC,,,,,Outpatient,,,2.4,,,,80,,1.92,percent of total billed charges,,,,85,2.04,percent of total billed charges,,,77.7,,1.86,percent of total billed charges,,,95,,2.28,percent of total billed charges,,,60,,1.44,percent of total billed charges,,1.44,2.28,
"FINGER CURVED PADDED 6""",101941,CDM,270,RC,,,,,Inpatient,,,2.4,,,,80,,1.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.86,percent of total billed charges,,,95,,2.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.28,
"FINGER CURVED PADDED 3""",101942,CDM,270,RC,,,,,Outpatient,,,3.1,,,,80,,2.48,percent of total billed charges,,,,85,2.64,percent of total billed charges,,,77.7,,2.41,percent of total billed charges,,,95,,2.95,percent of total billed charges,,,60,,1.86,percent of total billed charges,,1.86,2.95,
"FINGER CURVED PADDED 3""",101942,CDM,270,RC,,,,,Inpatient,,,3.1,,,,80,,2.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.41,percent of total billed charges,,,95,,2.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.95,
"FINGER CURVED PADDED 4""",101943,CDM,270,RC,,,,,Outpatient,,,3.1,,,,80,,2.48,percent of total billed charges,,,,85,2.64,percent of total billed charges,,,77.7,,2.41,percent of total billed charges,,,95,,2.95,percent of total billed charges,,,60,,1.86,percent of total billed charges,,1.86,2.95,
"FINGER CURVED PADDED 4""",101943,CDM,270,RC,,,,,Inpatient,,,3.1,,,,80,,2.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.41,percent of total billed charges,,,95,,2.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.95,
FINGER COT XLG,101944,CDM,270,RC,,,,,Outpatient,,,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
FINGER COT XLG,101944,CDM,270,RC,,,,,Inpatient,,,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
FINGER SPLINT CURVED,101945,CDM,270,RC,,,,,Outpatient,,,2.4,,,,80,,1.92,percent of total billed charges,,,,85,2.04,percent of total billed charges,,,77.7,,1.86,percent of total billed charges,,,95,,2.28,percent of total billed charges,,,60,,1.44,percent of total billed charges,,1.44,2.28,
FINGER SPLINT CURVED,101945,CDM,270,RC,,,,,Inpatient,,,2.4,,,,80,,1.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.86,percent of total billed charges,,,95,,2.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.28,
FINGER COT PADDED SMALL,101946,CDM,270,RC,,,,,Outpatient,,,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
FINGER COT PADDED SMALL,101946,CDM,270,RC,,,,,Inpatient,,,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
WRIST THUMB XSM LT SPLINT,101991,CDM,274,RC,L3809,HCPCS,,,Outpatient,,,43.6,,,,80,,34.88,percent of total billed charges,,,,85,37.06,percent of total billed charges,,,77.7,,33.88,percent of total billed charges,,,95,,41.42,percent of total billed charges,,,60,,26.16,percent of total billed charges,,26.16,41.42,
WRIST THUMB XSM LT SPLINT,101991,CDM,274,RC,L3809,HCPCS,,,Inpatient,,,43.6,,,,80,,34.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,33.88,percent of total billed charges,,,95,,41.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,41.42,
WRIST THUMB XSM RT SPLINT,101992,CDM,274,RC,L3809,HCPCS,,,Outpatient,,,43.6,,,,80,,34.88,percent of total billed charges,,,,85,37.06,percent of total billed charges,,,77.7,,33.88,percent of total billed charges,,,95,,41.42,percent of total billed charges,,,60,,26.16,percent of total billed charges,,26.16,41.42,
WRIST THUMB XSM RT SPLINT,101992,CDM,274,RC,L3809,HCPCS,,,Inpatient,,,43.6,,,,80,,34.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,33.88,percent of total billed charges,,,95,,41.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,41.42,
PERFORMA TRAK SE W/ELBOW SM,101994,CDM,270,RC,,,,,Outpatient,,,86.6,,,,80,,69.28,percent of total billed charges,,,,85,73.61,percent of total billed charges,,,77.7,,67.29,percent of total billed charges,,,95,,82.27,percent of total billed charges,,,60,,51.96,percent of total billed charges,,51.96,82.27,
PERFORMA TRAK SE W/ELBOW SM,101994,CDM,270,RC,,,,,Inpatient,,,86.6,,,,80,,69.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,67.29,percent of total billed charges,,,95,,82.27,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,82.27,
PERFORMA TRAK SE W/ELBOW MED,101995,CDM,270,RC,,,,,Outpatient,,,86.6,,,,80,,69.28,percent of total billed charges,,,,85,73.61,percent of total billed charges,,,77.7,,67.29,percent of total billed charges,,,95,,82.27,percent of total billed charges,,,60,,51.96,percent of total billed charges,,51.96,82.27,
PERFORMA TRAK SE W/ELBOW MED,101995,CDM,270,RC,,,,,Inpatient,,,86.6,,,,80,,69.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,67.29,percent of total billed charges,,,95,,82.27,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,82.27,
PERFORMA TRAK SE W/ELBOW LG,101996,CDM,270,RC,,,,,Outpatient,,,86.6,,,,80,,69.28,percent of total billed charges,,,,85,73.61,percent of total billed charges,,,77.7,,67.29,percent of total billed charges,,,95,,82.27,percent of total billed charges,,,60,,51.96,percent of total billed charges,,51.96,82.27,
PERFORMA TRAK SE W/ELBOW LG,101996,CDM,270,RC,,,,,Inpatient,,,86.6,,,,80,,69.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,67.29,percent of total billed charges,,,95,,82.27,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,82.27,
HEAT PAD LG 6X9 INSTANT,102005,CDM,270,RC,,,,,Outpatient,,,7.2,,,,80,,5.76,percent of total billed charges,,,,85,6.12,percent of total billed charges,,,77.7,,5.59,percent of total billed charges,,,95,,6.84,percent of total billed charges,,,60,,4.32,percent of total billed charges,,4.32,6.84,
HEAT PAD LG 6X9 INSTANT,102005,CDM,270,RC,,,,,Inpatient,,,7.2,,,,80,,5.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.59,percent of total billed charges,,,95,,6.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.84,
IVAS BONE BIOPSY,102011,CDM,270,RC,,,,,Outpatient,,,293.6,,,,80,,234.88,percent of total billed charges,,,,85,249.56,percent of total billed charges,,,77.7,,228.13,percent of total billed charges,,,95,,278.92,percent of total billed charges,,,60,,176.16,percent of total billed charges,,176.16,278.92,
IVAS BONE BIOPSY,102011,CDM,270,RC,,,,,Inpatient,,,293.6,,,,80,,234.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,228.13,percent of total billed charges,,,95,,278.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,278.92,
PRONEVIEW CUSHION INSERT STERILE,102013,CDM,270,RC,,,,,Outpatient,,,123.4,,,,80,,98.72,percent of total billed charges,,,,85,104.89,percent of total billed charges,,,77.7,,95.88,percent of total billed charges,,,95,,117.23,percent of total billed charges,,,60,,74.04,percent of total billed charges,,74.04,117.23,
PRONEVIEW CUSHION INSERT STERILE,102013,CDM,270,RC,,,,,Inpatient,,,123.4,,,,80,,98.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,95.88,percent of total billed charges,,,95,,117.23,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,117.23,
SUTURE 2-0 ETHIBOND X411H OR,102016,CDM,270,RC,,,,,Outpatient,,,7.7,,,,80,,6.16,percent of total billed charges,,,,85,6.55,percent of total billed charges,,,77.7,,5.98,percent of total billed charges,,,95,,7.32,percent of total billed charges,,,60,,4.62,percent of total billed charges,,4.62,7.32,
SUTURE 2-0 ETHIBOND X411H OR,102016,CDM,270,RC,,,,,Inpatient,,,7.7,,,,80,,6.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.98,percent of total billed charges,,,95,,7.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.32,
SUTURE 4-0 ETHIBOND X683G OR,102017,CDM,270,RC,,,,,Outpatient,,,6.6,,,,80,,5.28,percent of total billed charges,,,,85,5.61,percent of total billed charges,,,77.7,,5.13,percent of total billed charges,,,95,,6.27,percent of total billed charges,,,60,,3.96,percent of total billed charges,,3.96,6.27,
SUTURE 4-0 ETHIBOND X683G OR,102017,CDM,270,RC,,,,,Inpatient,,,6.6,,,,80,,5.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.13,percent of total billed charges,,,95,,6.27,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.27,
SHILEY TRACH 4MM INNER CANNULA,102019,CDM,270,RC,,,,,Outpatient,,,14,,,,80,,11.2,percent of total billed charges,,,,85,11.9,percent of total billed charges,,,77.7,,10.88,percent of total billed charges,,,95,,13.3,percent of total billed charges,,,60,,8.4,percent of total billed charges,,8.4,13.3,
SHILEY TRACH 4MM INNER CANNULA,102019,CDM,270,RC,,,,,Inpatient,,,14,,,,80,,11.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.88,percent of total billed charges,,,95,,13.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.3,
SUTURE O ETHIBOND CX21D OR,102020,CDM,270,RC,,,,,Outpatient,,,53.6,,,,80,,42.88,percent of total billed charges,,,,85,45.56,percent of total billed charges,,,77.7,,41.65,percent of total billed charges,,,95,,50.92,percent of total billed charges,,,60,,32.16,percent of total billed charges,,32.16,50.92,
SUTURE O ETHIBOND CX21D OR,102020,CDM,270,RC,,,,,Inpatient,,,53.6,,,,80,,42.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,41.65,percent of total billed charges,,,95,,50.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,50.92,
"FIBERWIRE 3-0 18""",102021,CDM,270,RC,,,,,Outpatient,,,77,,,,80,,61.6,percent of total billed charges,,,,85,65.45,percent of total billed charges,,,77.7,,59.83,percent of total billed charges,,,95,,73.15,percent of total billed charges,,,60,,46.2,percent of total billed charges,,46.2,73.15,
"FIBERWIRE 3-0 18""",102021,CDM,270,RC,,,,,Inpatient,,,77,,,,80,,61.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,59.83,percent of total billed charges,,,95,,73.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,73.15,
"FIBERWIRE 4-0 18""",102022,CDM,270,RC,,,,,Outpatient,,,77,,,,80,,61.6,percent of total billed charges,,,,85,65.45,percent of total billed charges,,,77.7,,59.83,percent of total billed charges,,,95,,73.15,percent of total billed charges,,,60,,46.2,percent of total billed charges,,46.2,73.15,
"FIBERWIRE 4-0 18""",102022,CDM,270,RC,,,,,Inpatient,,,77,,,,80,,61.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,59.83,percent of total billed charges,,,95,,73.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,73.15,
SUTURE TAPE 1.3MM W/NEEDLE WHITE/BLUE,102023,CDM,270,RC,,,,,Outpatient,,,122.5,,,,80,,98,percent of total billed charges,,,,85,104.13,percent of total billed charges,,,77.7,,95.18,percent of total billed charges,,,95,,116.38,percent of total billed charges,,,60,,73.5,percent of total billed charges,,73.5,116.38,
SUTURE TAPE 1.3MM W/NEEDLE WHITE/BLUE,102023,CDM,270,RC,,,,,Inpatient,,,122.5,,,,80,,98,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,95.18,percent of total billed charges,,,95,,116.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,116.38,
LEG HOLDER PAD,102027,CDM,270,RC,,,,,Outpatient,,,56.2,,,,80,,44.96,percent of total billed charges,,,,85,47.77,percent of total billed charges,,,77.7,,43.67,percent of total billed charges,,,95,,53.39,percent of total billed charges,,,60,,33.72,percent of total billed charges,,33.72,53.39,
LEG HOLDER PAD,102027,CDM,270,RC,,,,,Inpatient,,,56.2,,,,80,,44.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,43.67,percent of total billed charges,,,95,,53.39,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,53.39,
"K-WIRE D TROCAR 6""  0.7MM",102028,CDM,270,RC,,,,,Outpatient,,,9.8,,,,80,,7.84,percent of total billed charges,,,,85,8.33,percent of total billed charges,,,77.7,,7.61,percent of total billed charges,,,95,,9.31,percent of total billed charges,,,60,,5.88,percent of total billed charges,,5.88,9.31,
"K-WIRE D TROCAR 6""  0.7MM",102028,CDM,270,RC,,,,,Inpatient,,,9.8,,,,80,,7.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.61,percent of total billed charges,,,95,,9.31,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.31,
SUTURE 2-0 PROLENE 8411H OR,102029,CDM,270,RC,,,,,Outpatient,,,12,,,,80,,9.6,percent of total billed charges,,,,85,10.2,percent of total billed charges,,,77.7,,9.32,percent of total billed charges,,,95,,11.4,percent of total billed charges,,,60,,7.2,percent of total billed charges,,7.2,11.4,
SUTURE 2-0 PROLENE 8411H OR,102029,CDM,270,RC,,,,,Inpatient,,,12,,,,80,,9.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.32,percent of total billed charges,,,95,,11.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.4,
SUTURE 3-0 ETHIBOND X872H OR,102030,CDM,270,RC,,,,,Outpatient,,,9.6,,,,80,,7.68,percent of total billed charges,,,,85,8.16,percent of total billed charges,,,77.7,,7.46,percent of total billed charges,,,95,,9.12,percent of total billed charges,,,60,,5.76,percent of total billed charges,,5.76,9.12,
SUTURE 3-0 ETHIBOND X872H OR,102030,CDM,270,RC,,,,,Inpatient,,,9.6,,,,80,,7.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.46,percent of total billed charges,,,95,,9.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.12,
"K-WIRE D TROCAR 6""  0.9MM",102031,CDM,270,RC,,,,,Outpatient,,,9.9,,,,80,,7.92,percent of total billed charges,,,,85,8.42,percent of total billed charges,,,77.7,,7.69,percent of total billed charges,,,95,,9.41,percent of total billed charges,,,60,,5.94,percent of total billed charges,,5.94,9.41,
"K-WIRE D TROCAR 6""  0.9MM",102031,CDM,270,RC,,,,,Inpatient,,,9.9,,,,80,,7.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.69,percent of total billed charges,,,95,,9.41,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.41,
"K-WIRE D TROCAR 6""  1.1MM",102032,CDM,270,RC,,,,,Outpatient,,,10,,,,80,,8,percent of total billed charges,,,,85,8.5,percent of total billed charges,,,77.7,,7.77,percent of total billed charges,,,95,,9.5,percent of total billed charges,,,60,,6,percent of total billed charges,,6,9.5,
"K-WIRE D TROCAR 6""  1.1MM",102032,CDM,270,RC,,,,,Inpatient,,,10,,,,80,,8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.77,percent of total billed charges,,,95,,9.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.5,
"K-WIRE D TROCAR 6""  1.4MM",102033,CDM,270,RC,,,,,Outpatient,,,10.1,,,,80,,8.08,percent of total billed charges,,,,85,8.59,percent of total billed charges,,,77.7,,7.85,percent of total billed charges,,,95,,9.6,percent of total billed charges,,,60,,6.06,percent of total billed charges,,6.06,9.6,
"K-WIRE D TROCAR 6""  1.4MM",102033,CDM,270,RC,,,,,Inpatient,,,10.1,,,,80,,8.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.85,percent of total billed charges,,,95,,9.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.6,
"K-WIRE D TROCAR 6""  1.6MM",102034,CDM,270,RC,,,,,Outpatient,,,10.2,,,,80,,8.16,percent of total billed charges,,,,85,8.67,percent of total billed charges,,,77.7,,7.93,percent of total billed charges,,,95,,9.69,percent of total billed charges,,,60,,6.12,percent of total billed charges,,6.12,9.69,
"K-WIRE D TROCAR 6""  1.6MM",102034,CDM,270,RC,,,,,Inpatient,,,10.2,,,,80,,8.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.93,percent of total billed charges,,,95,,9.69,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.69,
"K-WIRE D TROCAR 9""  0.7MM",102035,CDM,270,RC,,,,,Outpatient,,,10.4,,,,80,,8.32,percent of total billed charges,,,,85,8.84,percent of total billed charges,,,77.7,,8.08,percent of total billed charges,,,95,,9.88,percent of total billed charges,,,60,,6.24,percent of total billed charges,,6.24,9.88,
"K-WIRE D TROCAR 9""  0.7MM",102035,CDM,270,RC,,,,,Inpatient,,,10.4,,,,80,,8.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.08,percent of total billed charges,,,95,,9.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.88,
"K-WIRE D TROCAR 9""  0.9MM",102036,CDM,270,RC,,,,,Outpatient,,,10.5,,,,80,,8.4,percent of total billed charges,,,,85,8.93,percent of total billed charges,,,77.7,,8.16,percent of total billed charges,,,95,,9.98,percent of total billed charges,,,60,,6.3,percent of total billed charges,,6.3,9.98,
"K-WIRE D TROCAR 9""  0.9MM",102036,CDM,270,RC,,,,,Inpatient,,,10.5,,,,80,,8.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.16,percent of total billed charges,,,95,,9.98,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.98,
"K-WIRE D TROCAR 9""  1.1MM",102037,CDM,270,RC,,,,,Outpatient,,,10.5,,,,80,,8.4,percent of total billed charges,,,,85,8.93,percent of total billed charges,,,77.7,,8.16,percent of total billed charges,,,95,,9.98,percent of total billed charges,,,60,,6.3,percent of total billed charges,,6.3,9.98,
"K-WIRE D TROCAR 9""  1.1MM",102037,CDM,270,RC,,,,,Inpatient,,,10.5,,,,80,,8.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.16,percent of total billed charges,,,95,,9.98,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.98,
"K-WIRE D TROCAR 9""  1.6MM",102038,CDM,270,RC,,,,,Outpatient,,,10.5,,,,80,,8.4,percent of total billed charges,,,,85,8.93,percent of total billed charges,,,77.7,,8.16,percent of total billed charges,,,95,,9.98,percent of total billed charges,,,60,,6.3,percent of total billed charges,,6.3,9.98,
"K-WIRE D TROCAR 9""  1.6MM",102038,CDM,270,RC,,,,,Inpatient,,,10.5,,,,80,,8.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.16,percent of total billed charges,,,95,,9.98,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.98,
"K-WIRE D TROCAR 9""  1.4MM",102039,CDM,270,RC,,,,,Outpatient,,,10.6,,,,80,,8.48,percent of total billed charges,,,,85,9.01,percent of total billed charges,,,77.7,,8.24,percent of total billed charges,,,95,,10.07,percent of total billed charges,,,60,,6.36,percent of total billed charges,,6.36,10.07,
"K-WIRE D TROCAR 9""  1.4MM",102039,CDM,270,RC,,,,,Inpatient,,,10.6,,,,80,,8.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.24,percent of total billed charges,,,95,,10.07,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.07,
SUTURE 0 PDS Z370T  OR,102040,CDM,270,RC,,,,,Outpatient,,,12.9,,,,80,,10.32,percent of total billed charges,,,,85,10.97,percent of total billed charges,,,77.7,,10.02,percent of total billed charges,,,95,,12.26,percent of total billed charges,,,60,,7.74,percent of total billed charges,,7.74,12.26,
SUTURE 0 PDS Z370T  OR,102040,CDM,270,RC,,,,,Inpatient,,,12.9,,,,80,,10.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.02,percent of total billed charges,,,95,,12.26,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,12.26,
SUTURE 2-0 PDS Z339H  OR,102041,CDM,270,RC,,,,,Outpatient,,,7.4,,,,80,,5.92,percent of total billed charges,,,,85,6.29,percent of total billed charges,,,77.7,,5.75,percent of total billed charges,,,95,,7.03,percent of total billed charges,,,60,,4.44,percent of total billed charges,,4.44,7.03,
SUTURE 2-0 PDS Z339H  OR,102041,CDM,270,RC,,,,,Inpatient,,,7.4,,,,80,,5.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.75,percent of total billed charges,,,95,,7.03,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.03,
SUTURE 3-0 PDS Z338H  OR,102042,CDM,270,RC,,,,,Outpatient,,,12.9,,,,80,,10.32,percent of total billed charges,,,,85,10.97,percent of total billed charges,,,77.7,,10.02,percent of total billed charges,,,95,,12.26,percent of total billed charges,,,60,,7.74,percent of total billed charges,,7.74,12.26,
SUTURE 3-0 PDS Z338H  OR,102042,CDM,270,RC,,,,,Inpatient,,,12.9,,,,80,,10.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.02,percent of total billed charges,,,95,,12.26,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,12.26,
SUTURE4-0 PDS Z441H  OR,102043,CDM,270,RC,,,,,Outpatient,,,11.7,,,,80,,9.36,percent of total billed charges,,,,85,9.95,percent of total billed charges,,,77.7,,9.09,percent of total billed charges,,,95,,11.12,percent of total billed charges,,,60,,7.02,percent of total billed charges,,7.02,11.12,
SUTURE4-0 PDS Z441H  OR,102043,CDM,270,RC,,,,,Inpatient,,,11.7,,,,80,,9.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.09,percent of total billed charges,,,95,,11.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.12,
SUTURE 0 PROLENE 8454H,102044,CDM,270,RC,,,,,Outpatient,,,11,,,,80,,8.8,percent of total billed charges,,,,85,9.35,percent of total billed charges,,,77.7,,8.55,percent of total billed charges,,,95,,10.45,percent of total billed charges,,,60,,6.6,percent of total billed charges,,6.6,10.45,
SUTURE 0 PROLENE 8454H,102044,CDM,270,RC,,,,,Inpatient,,,11,,,,80,,8.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.55,percent of total billed charges,,,95,,10.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.45,
SUTURE 0 VICRYL J946H OR,102045,CDM,270,RC,,,,,Outpatient,,,7.3,,,,80,,5.84,percent of total billed charges,,,,85,6.21,percent of total billed charges,,,77.7,,5.67,percent of total billed charges,,,95,,6.94,percent of total billed charges,,,60,,4.38,percent of total billed charges,,4.38,6.94,
SUTURE 0 VICRYL J946H OR,102045,CDM,270,RC,,,,,Inpatient,,,7.3,,,,80,,5.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.67,percent of total billed charges,,,95,,6.94,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.94,
SUTURE 2-0 VICRYL J945H OR,102046,CDM,270,RC,,,,,Outpatient,,,7.4,,,,80,,5.92,percent of total billed charges,,,,85,6.29,percent of total billed charges,,,77.7,,5.75,percent of total billed charges,,,95,,7.03,percent of total billed charges,,,60,,4.44,percent of total billed charges,,4.44,7.03,
SUTURE 2-0 VICRYL J945H OR,102046,CDM,270,RC,,,,,Inpatient,,,7.4,,,,80,,5.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.75,percent of total billed charges,,,95,,7.03,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.03,
SUTURE BONE WAX W31G,102047,CDM,270,RC,,,,,Outpatient,,,24.3,,,,80,,19.44,percent of total billed charges,,,,85,20.66,percent of total billed charges,,,77.7,,18.88,percent of total billed charges,,,95,,23.09,percent of total billed charges,,,60,,14.58,percent of total billed charges,,14.58,23.09,
SUTURE BONE WAX W31G,102047,CDM,270,RC,,,,,Inpatient,,,24.3,,,,80,,19.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,18.88,percent of total billed charges,,,95,,23.09,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,23.09,
GIGLI SAW BLADE 40cm,102048,CDM,270,RC,,,,,Outpatient,,,44.6,,,,80,,35.68,percent of total billed charges,,,,85,37.91,percent of total billed charges,,,77.7,,34.65,percent of total billed charges,,,95,,42.37,percent of total billed charges,,,60,,26.76,percent of total billed charges,,26.76,42.37,
GIGLI SAW BLADE 40cm,102048,CDM,270,RC,,,,,Inpatient,,,44.6,,,,80,,35.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,34.65,percent of total billed charges,,,95,,42.37,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,42.37,
APOLLO RF 90 DEGR MULTIPORT,102050,CDM,270,RC,,,,,Outpatient,,,665,,,,80,,532,percent of total billed charges,,,,85,565.25,percent of total billed charges,,,77.7,,516.71,percent of total billed charges,,,95,,631.75,percent of total billed charges,,,60,,399,percent of total billed charges,,399,631.75,
APOLLO RF 90 DEGR MULTIPORT,102050,CDM,270,RC,,,,,Inpatient,,,665,,,,80,,532,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,516.71,percent of total billed charges,,,95,,631.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,631.75,
APOLLO 50 DEGR,102051,CDM,270,RC,,,,,Outpatient,,,696.5,,,,80,,557.2,percent of total billed charges,,,,85,592.03,percent of total billed charges,,,77.7,,541.18,percent of total billed charges,,,95,,661.68,percent of total billed charges,,,60,,417.9,percent of total billed charges,,417.9,661.68,
APOLLO 50 DEGR,102051,CDM,270,RC,,,,,Inpatient,,,696.5,,,,80,,557.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,541.18,percent of total billed charges,,,95,,661.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,661.68,
SHAVER BLADE TORPEDO 4.0MMX13CM,102052,CDM,270,RC,,,,,Outpatient,,,353.5,,,,80,,282.8,percent of total billed charges,,,,85,300.48,percent of total billed charges,,,77.7,,274.67,percent of total billed charges,,,95,,335.83,percent of total billed charges,,,60,,212.1,percent of total billed charges,,212.1,335.83,
SHAVER BLADE TORPEDO 4.0MMX13CM,102052,CDM,270,RC,,,,,Inpatient,,,353.5,,,,80,,282.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,274.67,percent of total billed charges,,,95,,335.83,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,335.83,
SHAVER BLADE DOUBLE CUT 4.0MMX13CM,102053,CDM,270,RC,,,,,Outpatient,,,172.1,,,,80,,137.68,percent of total billed charges,,,,85,146.29,percent of total billed charges,,,77.7,,133.72,percent of total billed charges,,,95,,163.5,percent of total billed charges,,,60,,103.26,percent of total billed charges,,103.26,163.5,
SHAVER BLADE DOUBLE CUT 4.0MMX13CM,102053,CDM,270,RC,,,,,Inpatient,,,172.1,,,,80,,137.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,133.72,percent of total billed charges,,,95,,163.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,163.5,
"BURR, OVAL, FLUSH CUT 8 FLUT, 5.0MMX13CM",102054,CDM,270,RC,,,,,Outpatient,,,38.8,,,,80,,31.04,percent of total billed charges,,,,85,32.98,percent of total billed charges,,,77.7,,30.15,percent of total billed charges,,,95,,36.86,percent of total billed charges,,,60,,23.28,percent of total billed charges,,23.28,36.86,
"BURR, OVAL, FLUSH CUT 8 FLUT, 5.0MMX13CM",102054,CDM,270,RC,,,,,Inpatient,,,38.8,,,,80,,31.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,30.15,percent of total billed charges,,,95,,36.86,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,36.86,
TUBE SET INFLOW ARTHROSCOPY,102055,CDM,270,RC,,,,,Outpatient,,,157.5,,,,80,,126,percent of total billed charges,,,,85,133.88,percent of total billed charges,,,77.7,,122.38,percent of total billed charges,,,95,,149.63,percent of total billed charges,,,60,,94.5,percent of total billed charges,,94.5,149.63,
TUBE SET INFLOW ARTHROSCOPY,102055,CDM,270,RC,,,,,Inpatient,,,157.5,,,,80,,126,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,122.38,percent of total billed charges,,,95,,149.63,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,149.63,
"BURR, OVAL, 8 FLUT 4.0MM X 13CM",102056,CDM,270,RC,,,,,Outpatient,,,157.5,,,,80,,126,percent of total billed charges,,,,85,133.88,percent of total billed charges,,,77.7,,122.38,percent of total billed charges,,,95,,149.63,percent of total billed charges,,,60,,94.5,percent of total billed charges,,94.5,149.63,
"BURR, OVAL, 8 FLUT 4.0MM X 13CM",102056,CDM,270,RC,,,,,Inpatient,,,157.5,,,,80,,126,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,122.38,percent of total billed charges,,,95,,149.63,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,149.63,
"SONICBEAT 10cm, 5mm, INLINE",102057,CDM,270,RC,,,,,Outpatient,,,1015,,,,80,,812,percent of total billed charges,,,,85,862.75,percent of total billed charges,,,77.7,,788.66,percent of total billed charges,,,95,,964.25,percent of total billed charges,,,60,,609,percent of total billed charges,,609,964.25,
"SONICBEAT 10cm, 5mm, INLINE",102057,CDM,270,RC,,,,,Inpatient,,,1015,,,,80,,812,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,788.66,percent of total billed charges,,,95,,964.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,964.25,
BIOCOMPOSITE SWIVELOCK C 4.75X19.1MM,102058,CDM,278,RC,C2625,HCPCS,,,Outpatient,,,2002,,,,80,,1601.6,percent of total billed charges,,,,85,1701.7,percent of total billed charges,,,77.7,,1555.55,percent of total billed charges,,,95,,1901.9,percent of total billed charges,,,60,,1201.2,percent of total billed charges,,1201.2,1901.9,
BIOCOMPOSITE SWIVELOCK C 4.75X19.1MM,102058,CDM,278,RC,C2625,HCPCS,,,Inpatient,,,2002,,,,80,,1601.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1555.55,percent of total billed charges,,,95,,1901.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1901.9,
C2625 PEEK SWIVELOCK C ANCHOR 4.75X19.1MM,102059,CDM,278,RC,C2625,HCPCS,,,Outpatient,,,1876,,,,80,,1500.8,percent of total billed charges,,,,85,1594.6,percent of total billed charges,,,77.7,,1457.65,percent of total billed charges,,,95,,1782.2,percent of total billed charges,,,60,,1125.6,percent of total billed charges,,1125.6,1782.2,
C2625 PEEK SWIVELOCK C ANCHOR 4.75X19.1MM,102059,CDM,278,RC,C2625,HCPCS,,,Inpatient,,,1876,,,,80,,1500.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1457.65,percent of total billed charges,,,95,,1782.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1782.2,
C2625 IMPLANT SYSTEM INTERNAL KNEE LIGAMENT,102060,CDM,278,RC,C2625,HCPCS,,,Outpatient,,,5978,,,,80,,4782.4,percent of total billed charges,,,,85,5081.3,percent of total billed charges,,,77.7,,4644.91,percent of total billed charges,,,95,,5679.1,percent of total billed charges,,,60,,3586.8,percent of total billed charges,,3586.8,5679.1,
C2625 IMPLANT SYSTEM INTERNAL KNEE LIGAMENT,102060,CDM,278,RC,C2625,HCPCS,,,Inpatient,,,5978,,,,80,,4782.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4644.91,percent of total billed charges,,,95,,5679.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5679.1,
C1751 PIC LINE 5FR TRIPLE LUMEN,102062,CDM,278,RC,C1751,HCPCS,,,Outpatient,,,471.8,,,,80,,377.44,percent of total billed charges,,,,85,401.03,percent of total billed charges,,,77.7,,366.59,percent of total billed charges,,,95,,448.21,percent of total billed charges,,,60,,283.08,percent of total billed charges,,283.08,448.21,
C1751 PIC LINE 5FR TRIPLE LUMEN,102062,CDM,278,RC,C1751,HCPCS,,,Inpatient,,,471.8,,,,80,,377.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,366.59,percent of total billed charges,,,95,,448.21,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,448.21,
SHAVER EXCALIBUR 4.0MM X 13CM,102064,CDM,270,RC,,,,,Outpatient,,,206.5,,,,80,,165.2,percent of total billed charges,,,,85,175.53,percent of total billed charges,,,77.7,,160.45,percent of total billed charges,,,95,,196.18,percent of total billed charges,,,60,,123.9,percent of total billed charges,,123.9,196.18,
SHAVER EXCALIBUR 4.0MM X 13CM,102064,CDM,270,RC,,,,,Inpatient,,,206.5,,,,80,,165.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,160.45,percent of total billed charges,,,95,,196.18,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,196.18,
NEEDLE KEITH STR TRI 1.5,102081,CDM,270,RC,,,,,Outpatient,,,550.7,,,,80,,440.56,percent of total billed charges,,,,85,468.1,percent of total billed charges,,,77.7,,427.89,percent of total billed charges,,,95,,523.17,percent of total billed charges,,,60,,330.42,percent of total billed charges,,330.42,523.17,
NEEDLE KEITH STR TRI 1.5,102081,CDM,270,RC,,,,,Inpatient,,,550.7,,,,80,,440.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,427.89,percent of total billed charges,,,95,,523.17,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,523.17,
NEEDLE KEITH STR TRI 2,102082,CDM,270,RC,,,,,Outpatient,,,550.7,,,,80,,440.56,percent of total billed charges,,,,85,468.1,percent of total billed charges,,,77.7,,427.89,percent of total billed charges,,,95,,523.17,percent of total billed charges,,,60,,330.42,percent of total billed charges,,330.42,523.17,
NEEDLE KEITH STR TRI 2,102082,CDM,270,RC,,,,,Inpatient,,,550.7,,,,80,,440.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,427.89,percent of total billed charges,,,95,,523.17,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,523.17,
NEEDLE KEITH STR TRI 4,102083,CDM,270,RC,,,,,Outpatient,,,467.4,,,,80,,373.92,percent of total billed charges,,,,85,397.29,percent of total billed charges,,,77.7,,363.17,percent of total billed charges,,,95,,444.03,percent of total billed charges,,,60,,280.44,percent of total billed charges,,280.44,444.03,
NEEDLE KEITH STR TRI 4,102083,CDM,270,RC,,,,,Inpatient,,,467.4,,,,80,,373.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,363.17,percent of total billed charges,,,95,,444.03,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,444.03,
NEEDLE MAYO CATGUT SIZE 4,102084,CDM,270,RC,,,,,Outpatient,,,62.9,,,,80,,50.32,percent of total billed charges,,,,85,53.47,percent of total billed charges,,,77.7,,48.87,percent of total billed charges,,,95,,59.76,percent of total billed charges,,,60,,37.74,percent of total billed charges,,37.74,59.76,
NEEDLE MAYO CATGUT SIZE 4,102084,CDM,270,RC,,,,,Inpatient,,,62.9,,,,80,,50.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,48.87,percent of total billed charges,,,95,,59.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,59.76,
NEEDLE MAYO CATGUT SIZE 5,102085,CDM,270,RC,,,,,Outpatient,,,18,,,,80,,14.4,percent of total billed charges,,,,85,15.3,percent of total billed charges,,,77.7,,13.99,percent of total billed charges,,,95,,17.1,percent of total billed charges,,,60,,10.8,percent of total billed charges,,10.8,17.1,
NEEDLE MAYO CATGUT SIZE 5,102085,CDM,270,RC,,,,,Inpatient,,,18,,,,80,,14.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,13.99,percent of total billed charges,,,95,,17.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.1,
CO2 MICROSTREAM CAPNOLINE (NASAL CO2 LINE OR),102086,CDM,270,RC,,,,,Outpatient,,,42.2,,,,80,,33.76,percent of total billed charges,,,,85,35.87,percent of total billed charges,,,77.7,,32.79,percent of total billed charges,,,95,,40.09,percent of total billed charges,,,60,,25.32,percent of total billed charges,,25.32,40.09,
CO2 MICROSTREAM CAPNOLINE (NASAL CO2 LINE OR),102086,CDM,270,RC,,,,,Inpatient,,,42.2,,,,80,,33.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,32.79,percent of total billed charges,,,95,,40.09,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,40.09,
FIBERWIRE 2-0 BLUE,102087,CDM,270,RC,,,,,Outpatient,,,77,,,,80,,61.6,percent of total billed charges,,,,85,65.45,percent of total billed charges,,,77.7,,59.83,percent of total billed charges,,,95,,73.15,percent of total billed charges,,,60,,46.2,percent of total billed charges,,46.2,73.15,
FIBERWIRE 2-0 BLUE,102087,CDM,270,RC,,,,,Inpatient,,,77,,,,80,,61.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,59.83,percent of total billed charges,,,95,,73.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,73.15,
IVAS BONE BIOPSY 13G,102089,CDM,270,RC,,,,,Outpatient,,,355.4,,,,80,,284.32,percent of total billed charges,,,,85,302.09,percent of total billed charges,,,77.7,,276.15,percent of total billed charges,,,95,,337.63,percent of total billed charges,,,60,,213.24,percent of total billed charges,,213.24,337.63,
IVAS BONE BIOPSY 13G,102089,CDM,270,RC,,,,,Inpatient,,,355.4,,,,80,,284.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,276.15,percent of total billed charges,,,95,,337.63,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,337.63,
KYPHOPLASTY HAND DRILL 13G,102090,CDM,270,RC,,,,,Outpatient,,,368,,,,80,,294.4,percent of total billed charges,,,,85,312.8,percent of total billed charges,,,77.7,,285.94,percent of total billed charges,,,95,,349.6,percent of total billed charges,,,60,,220.8,percent of total billed charges,,220.8,349.6,
KYPHOPLASTY HAND DRILL 13G,102090,CDM,270,RC,,,,,Inpatient,,,368,,,,80,,294.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,285.94,percent of total billed charges,,,95,,349.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,349.6,
C1781 MESH ADVANTAGE FIT BLUE,102091,CDM,278,RC,C1781,HCPCS,,,Outpatient,,,6310.3,,,,80,,5048.24,percent of total billed charges,,,,85,5363.76,percent of total billed charges,,,77.7,,4903.1,percent of total billed charges,,,95,,5994.79,percent of total billed charges,,,60,,3786.18,percent of total billed charges,,3786.18,5994.79,
C1781 MESH ADVANTAGE FIT BLUE,102091,CDM,278,RC,C1781,HCPCS,,,Inpatient,,,6310.3,,,,80,,5048.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4903.1,percent of total billed charges,,,95,,5994.79,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5994.79,
RESOLUTION 36O CLIP ENDO,102095,CDM,270,RC,,,,,Outpatient,,,889,,,,80,,711.2,percent of total billed charges,,,,85,755.65,percent of total billed charges,,,77.7,,690.75,percent of total billed charges,,,95,,844.55,percent of total billed charges,,,60,,533.4,percent of total billed charges,,533.4,844.55,
RESOLUTION 36O CLIP ENDO,102095,CDM,270,RC,,,,,Inpatient,,,889,,,,80,,711.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,690.75,percent of total billed charges,,,95,,844.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,844.55,
SUTURE 1-0 MONOCRYL OR,102097,CDM,270,RC,,,,,Outpatient,,,8.4,,,,80,,6.72,percent of total billed charges,,,,85,7.14,percent of total billed charges,,,77.7,,6.53,percent of total billed charges,,,95,,7.98,percent of total billed charges,,,60,,5.04,percent of total billed charges,,5.04,7.98,
SUTURE 1-0 MONOCRYL OR,102097,CDM,270,RC,,,,,Inpatient,,,8.4,,,,80,,6.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.53,percent of total billed charges,,,95,,7.98,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.98,
SUTURE 3-0 MONOFILAMENT OR,102098,CDM,270,RC,,,,,Outpatient,,,10,,,,80,,8,percent of total billed charges,,,,85,8.5,percent of total billed charges,,,77.7,,7.77,percent of total billed charges,,,95,,9.5,percent of total billed charges,,,60,,6,percent of total billed charges,,6,9.5,
SUTURE 3-0 MONOFILAMENT OR,102098,CDM,270,RC,,,,,Inpatient,,,10,,,,80,,8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.77,percent of total billed charges,,,95,,9.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.5,
SUTURE O-VIOLET PDSII OR,102099,CDM,270,RC,,,,,Outpatient,,,5.4,,,,80,,4.32,percent of total billed charges,,,,85,4.59,percent of total billed charges,,,77.7,,4.2,percent of total billed charges,,,95,,5.13,percent of total billed charges,,,60,,3.24,percent of total billed charges,,3.24,5.13,
SUTURE O-VIOLET PDSII OR,102099,CDM,270,RC,,,,,Inpatient,,,5.4,,,,80,,4.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.2,percent of total billed charges,,,95,,5.13,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.13,
SUTURE 3-0 PLAINGUT OR,102100,CDM,270,RC,,,,,Outpatient,,,8.6,,,,80,,6.88,percent of total billed charges,,,,85,7.31,percent of total billed charges,,,77.7,,6.68,percent of total billed charges,,,95,,8.17,percent of total billed charges,,,60,,5.16,percent of total billed charges,,5.16,8.17,
SUTURE 3-0 PLAINGUT OR,102100,CDM,270,RC,,,,,Inpatient,,,8.6,,,,80,,6.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.68,percent of total billed charges,,,95,,8.17,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,8.17,
SUTURE 3-0 VICRYL OR,102101,CDM,270,RC,,,,,Outpatient,,,4.4,,,,80,,3.52,percent of total billed charges,,,,85,3.74,percent of total billed charges,,,77.7,,3.42,percent of total billed charges,,,95,,4.18,percent of total billed charges,,,60,,2.64,percent of total billed charges,,2.64,4.18,
SUTURE 3-0 VICRYL OR,102101,CDM,270,RC,,,,,Inpatient,,,4.4,,,,80,,3.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.42,percent of total billed charges,,,95,,4.18,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.18,
"SPLINT ORTHO PRECUT 2""X12""",102107,CDM,270,RC,,,,,Outpatient,,,13.3,,,,80,,10.64,percent of total billed charges,,,,85,11.31,percent of total billed charges,,,77.7,,10.33,percent of total billed charges,,,95,,12.64,percent of total billed charges,,,60,,7.98,percent of total billed charges,,7.98,12.64,
"SPLINT ORTHO PRECUT 2""X12""",102107,CDM,270,RC,,,,,Inpatient,,,13.3,,,,80,,10.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.33,percent of total billed charges,,,95,,12.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,12.64,
"SPLINT ORTHO PRECUT 3""X12""",102108,CDM,270,RC,,,,,Outpatient,,,16,,,,80,,12.8,percent of total billed charges,,,,85,13.6,percent of total billed charges,,,77.7,,12.43,percent of total billed charges,,,95,,15.2,percent of total billed charges,,,60,,9.6,percent of total billed charges,,9.6,15.2,
"SPLINT ORTHO PRECUT 3""X12""",102108,CDM,270,RC,,,,,Inpatient,,,16,,,,80,,12.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.43,percent of total billed charges,,,95,,15.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.2,
"SPLINT ORTHO PRECUT 3""X35""",102109,CDM,270,RC,,,,,Outpatient,,,45.9,,,,80,,36.72,percent of total billed charges,,,,85,39.02,percent of total billed charges,,,77.7,,35.66,percent of total billed charges,,,95,,43.61,percent of total billed charges,,,60,,27.54,percent of total billed charges,,27.54,43.61,
"SPLINT ORTHO PRECUT 3""X35""",102109,CDM,270,RC,,,,,Inpatient,,,45.9,,,,80,,36.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,35.66,percent of total billed charges,,,95,,43.61,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,43.61,
"SPLINT ORTHO PRECUT 4""X15""",102110,CDM,270,RC,,,,,Outpatient,,,22.2,,,,80,,17.76,percent of total billed charges,,,,85,18.87,percent of total billed charges,,,77.7,,17.25,percent of total billed charges,,,95,,21.09,percent of total billed charges,,,60,,13.32,percent of total billed charges,,13.32,21.09,
"SPLINT ORTHO PRECUT 4""X15""",102110,CDM,270,RC,,,,,Inpatient,,,22.2,,,,80,,17.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,17.25,percent of total billed charges,,,95,,21.09,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,21.09,
"SPLINT ORTHO PRECUT 4""X30""",102111,CDM,270,RC,,,,,Outpatient,,,36.9,,,,80,,29.52,percent of total billed charges,,,,85,31.37,percent of total billed charges,,,77.7,,28.67,percent of total billed charges,,,95,,35.06,percent of total billed charges,,,60,,22.14,percent of total billed charges,,22.14,35.06,
"SPLINT ORTHO PRECUT 4""X30""",102111,CDM,270,RC,,,,,Inpatient,,,36.9,,,,80,,29.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,28.67,percent of total billed charges,,,95,,35.06,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,35.06,
KNOT PUSHER/SUTURE CUTTER W/PORTAL SKID,102116,CDM,270,RC,,,,,Outpatient,,,1102.5,,,,80,,882,percent of total billed charges,,,,85,937.13,percent of total billed charges,,,77.7,,856.64,percent of total billed charges,,,95,,1047.38,percent of total billed charges,,,60,,661.5,percent of total billed charges,,661.5,1047.38,
KNOT PUSHER/SUTURE CUTTER W/PORTAL SKID,102116,CDM,270,RC,,,,,Inpatient,,,1102.5,,,,80,,882,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,856.64,percent of total billed charges,,,95,,1047.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1047.38,
FOLEY CATH KIT 16FR LF W/SILVER,102117,CDM,270,RC,,,,,Outpatient,,,49.2,,,,80,,39.36,percent of total billed charges,,,,85,41.82,percent of total billed charges,,,77.7,,38.23,percent of total billed charges,,,95,,46.74,percent of total billed charges,,,60,,29.52,percent of total billed charges,,29.52,46.74,
FOLEY CATH KIT 16FR LF W/SILVER,102117,CDM,270,RC,,,,,Inpatient,,,49.2,,,,80,,39.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,38.23,percent of total billed charges,,,95,,46.74,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,46.74,
HOTLINE WARMING SET,102119,CDM,270,RC,,,,,Outpatient,,,32.3,,,,80,,25.84,percent of total billed charges,,,,85,27.46,percent of total billed charges,,,77.7,,25.1,percent of total billed charges,,,95,,30.69,percent of total billed charges,,,60,,19.38,percent of total billed charges,,19.38,30.69,
HOTLINE WARMING SET,102119,CDM,270,RC,,,,,Inpatient,,,32.3,,,,80,,25.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,25.1,percent of total billed charges,,,95,,30.69,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,30.69,
UTERINE MANIPULATOR 7CM TIP,102121,CDM,270,RC,,,,,Outpatient,,,564.9,,,,80,,451.92,percent of total billed charges,,,,85,480.17,percent of total billed charges,,,77.7,,438.93,percent of total billed charges,,,95,,536.66,percent of total billed charges,,,60,,338.94,percent of total billed charges,,338.94,536.66,
UTERINE MANIPULATOR 7CM TIP,102121,CDM,270,RC,,,,,Inpatient,,,564.9,,,,80,,451.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,438.93,percent of total billed charges,,,95,,536.66,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,536.66,
OPTIFOAM 4x4 GENTLE SILICONE,102149,CDM,270,RC,,,,,Outpatient,,,8.9,,,,80,,7.12,percent of total billed charges,,,,85,7.57,percent of total billed charges,,,77.7,,6.92,percent of total billed charges,,,95,,8.46,percent of total billed charges,,,60,,5.34,percent of total billed charges,,5.34,8.46,
OPTIFOAM 4x4 GENTLE SILICONE,102149,CDM,270,RC,,,,,Inpatient,,,8.9,,,,80,,7.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.92,percent of total billed charges,,,95,,8.46,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,8.46,
REMOVER LOTION 4 OZ,102150,CDM,270,RC,,,,,Outpatient,,,11.8,,,,80,,9.44,percent of total billed charges,,,,85,10.03,percent of total billed charges,,,77.7,,9.17,percent of total billed charges,,,95,,11.21,percent of total billed charges,,,60,,7.08,percent of total billed charges,,7.08,11.21,
REMOVER LOTION 4 OZ,102150,CDM,270,RC,,,,,Inpatient,,,11.8,,,,80,,9.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.17,percent of total billed charges,,,95,,11.21,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.21,
HEATED VENT CIRCUIT NEONATE/INFANT,102152,CDM,270,RC,,,,,Outpatient,,,136.5,,,,80,,109.2,percent of total billed charges,,,,85,116.03,percent of total billed charges,,,77.7,,106.06,percent of total billed charges,,,95,,129.68,percent of total billed charges,,,60,,81.9,percent of total billed charges,,81.9,129.68,
HEATED VENT CIRCUIT NEONATE/INFANT,102152,CDM,270,RC,,,,,Inpatient,,,136.5,,,,80,,109.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,106.06,percent of total billed charges,,,95,,129.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,129.68,
CANNULA NASAL HIGH FLOW SMALL,102153,CDM,270,RC,,,,,Outpatient,,,79.4,,,,80,,63.52,percent of total billed charges,,,,85,67.49,percent of total billed charges,,,77.7,,61.69,percent of total billed charges,,,95,,75.43,percent of total billed charges,,,60,,47.64,percent of total billed charges,,47.64,75.43,
CANNULA NASAL HIGH FLOW SMALL,102153,CDM,270,RC,,,,,Inpatient,,,79.4,,,,80,,63.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,61.69,percent of total billed charges,,,95,,75.43,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,75.43,
CANNULA NASAL HIGH FLOW MED,102154,CDM,270,RC,,,,,Outpatient,,,79.4,,,,80,,63.52,percent of total billed charges,,,,85,67.49,percent of total billed charges,,,77.7,,61.69,percent of total billed charges,,,95,,75.43,percent of total billed charges,,,60,,47.64,percent of total billed charges,,47.64,75.43,
CANNULA NASAL HIGH FLOW MED,102154,CDM,270,RC,,,,,Inpatient,,,79.4,,,,80,,63.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,61.69,percent of total billed charges,,,95,,75.43,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,75.43,
CANNULA NASAL HIGH FLOW LG,102155,CDM,270,RC,,,,,Outpatient,,,79.4,,,,80,,63.52,percent of total billed charges,,,,85,67.49,percent of total billed charges,,,77.7,,61.69,percent of total billed charges,,,95,,75.43,percent of total billed charges,,,60,,47.64,percent of total billed charges,,47.64,75.43,
CANNULA NASAL HIGH FLOW LG,102155,CDM,270,RC,,,,,Inpatient,,,79.4,,,,80,,63.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,61.69,percent of total billed charges,,,95,,75.43,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,75.43,
CIRCUIT SINGLE LIMB,102156,CDM,270,RC,,,,,Outpatient,,,190.3,,,,80,,152.24,percent of total billed charges,,,,85,161.76,percent of total billed charges,,,77.7,,147.86,percent of total billed charges,,,95,,180.79,percent of total billed charges,,,60,,114.18,percent of total billed charges,,114.18,180.79,
CIRCUIT SINGLE LIMB,102156,CDM,270,RC,,,,,Inpatient,,,190.3,,,,80,,152.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,147.86,percent of total billed charges,,,95,,180.79,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,180.79,
FILTER  NEONATE EXP PB980,102157,CDM,270,RC,,,,,Outpatient,,,51.1,,,,80,,40.88,percent of total billed charges,,,,85,43.44,percent of total billed charges,,,77.7,,39.7,percent of total billed charges,,,95,,48.55,percent of total billed charges,,,60,,30.66,percent of total billed charges,,30.66,48.55,
FILTER  NEONATE EXP PB980,102157,CDM,270,RC,,,,,Inpatient,,,51.1,,,,80,,40.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,39.7,percent of total billed charges,,,95,,48.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,48.55,
LARYNGEAL i-GEL SM,102159,CDM,270,RC,,,,,Outpatient,,,121,,,,80,,96.8,percent of total billed charges,,,,85,102.85,percent of total billed charges,,,77.7,,94.02,percent of total billed charges,,,95,,114.95,percent of total billed charges,,,60,,72.6,percent of total billed charges,,72.6,114.95,
LARYNGEAL i-GEL SM,102159,CDM,270,RC,,,,,Inpatient,,,121,,,,80,,96.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,94.02,percent of total billed charges,,,95,,114.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,114.95,
LARYNGEAL i-GEL MED,102160,CDM,270,RC,,,,,Outpatient,,,132.9,,,,80,,106.32,percent of total billed charges,,,,85,112.97,percent of total billed charges,,,77.7,,103.26,percent of total billed charges,,,95,,126.26,percent of total billed charges,,,60,,79.74,percent of total billed charges,,79.74,126.26,
LARYNGEAL i-GEL MED,102160,CDM,270,RC,,,,,Inpatient,,,132.9,,,,80,,106.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,103.26,percent of total billed charges,,,95,,126.26,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,126.26,
LARYNGEAL i-GEL LG,102161,CDM,270,RC,,,,,Outpatient,,,121,,,,80,,96.8,percent of total billed charges,,,,85,102.85,percent of total billed charges,,,77.7,,94.02,percent of total billed charges,,,95,,114.95,percent of total billed charges,,,60,,72.6,percent of total billed charges,,72.6,114.95,
LARYNGEAL i-GEL LG,102161,CDM,270,RC,,,,,Inpatient,,,121,,,,80,,96.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,94.02,percent of total billed charges,,,95,,114.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,114.95,
SUTURE 4-0 VICRYL ETHJ464G,102169,CDM,270,RC,,,,,Outpatient,,,12.3,,,,80,,9.84,percent of total billed charges,,,,85,10.46,percent of total billed charges,,,77.7,,9.56,percent of total billed charges,,,95,,11.69,percent of total billed charges,,,60,,7.38,percent of total billed charges,,7.38,11.69,
SUTURE 4-0 VICRYL ETHJ464G,102169,CDM,270,RC,,,,,Inpatient,,,12.3,,,,80,,9.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.56,percent of total billed charges,,,95,,11.69,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.69,
GRASPING DEVICE TALON,102176,CDM,270,RC,,,,,Outpatient,,,500.5,,,,80,,400.4,percent of total billed charges,,,,85,425.43,percent of total billed charges,,,77.7,,388.89,percent of total billed charges,,,95,,475.48,percent of total billed charges,,,60,,300.3,percent of total billed charges,,300.3,475.48,
GRASPING DEVICE TALON,102176,CDM,270,RC,,,,,Inpatient,,,500.5,,,,80,,400.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,388.89,percent of total billed charges,,,95,,475.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,475.48,
CANNULA RAM PREEMIE,102180,CDM,270,RC,,,,,Outpatient,,,35.2,,,,80,,28.16,percent of total billed charges,,,,85,29.92,percent of total billed charges,,,77.7,,27.35,percent of total billed charges,,,95,,33.44,percent of total billed charges,,,60,,21.12,percent of total billed charges,,21.12,33.44,
CANNULA RAM PREEMIE,102180,CDM,270,RC,,,,,Inpatient,,,35.2,,,,80,,28.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,27.35,percent of total billed charges,,,95,,33.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,33.44,
CANNULA RAM NEWBORN,102181,CDM,270,RC,,,,,Outpatient,,,35.2,,,,80,,28.16,percent of total billed charges,,,,85,29.92,percent of total billed charges,,,77.7,,27.35,percent of total billed charges,,,95,,33.44,percent of total billed charges,,,60,,21.12,percent of total billed charges,,21.12,33.44,
CANNULA RAM NEWBORN,102181,CDM,270,RC,,,,,Inpatient,,,35.2,,,,80,,28.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,27.35,percent of total billed charges,,,95,,33.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,33.44,
CANNULA RAM INFANT,102182,CDM,270,RC,,,,,Outpatient,,,35.2,,,,80,,28.16,percent of total billed charges,,,,85,29.92,percent of total billed charges,,,77.7,,27.35,percent of total billed charges,,,95,,33.44,percent of total billed charges,,,60,,21.12,percent of total billed charges,,21.12,33.44,
CANNULA RAM INFANT,102182,CDM,270,RC,,,,,Inpatient,,,35.2,,,,80,,28.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,27.35,percent of total billed charges,,,95,,33.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,33.44,
"SPLINT ORTHO PRECUT 5""X30""",102184,CDM,270,RC,,,,,Outpatient,,,45.8,,,,80,,36.64,percent of total billed charges,,,,85,38.93,percent of total billed charges,,,77.7,,35.59,percent of total billed charges,,,95,,43.51,percent of total billed charges,,,60,,27.48,percent of total billed charges,,27.48,43.51,
"SPLINT ORTHO PRECUT 5""X30""",102184,CDM,270,RC,,,,,Inpatient,,,45.8,,,,80,,36.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,35.59,percent of total billed charges,,,95,,43.51,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,43.51,
OPTIFOAM 4X4 DRESSING,102185,CDM,270,RC,,,,,Outpatient,,,30.6,,,,80,,24.48,percent of total billed charges,,,,85,26.01,percent of total billed charges,,,77.7,,23.78,percent of total billed charges,,,95,,29.07,percent of total billed charges,,,60,,18.36,percent of total billed charges,,18.36,29.07,
OPTIFOAM 4X4 DRESSING,102185,CDM,270,RC,,,,,Inpatient,,,30.6,,,,80,,24.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,23.78,percent of total billed charges,,,95,,29.07,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,29.07,
XEROFORM 5X9 PETROLATUM DRESSING,102191,CDM,270,RC,,,,,Outpatient,,,1.7,,,,80,,1.36,percent of total billed charges,,,,85,1.45,percent of total billed charges,,,77.7,,1.32,percent of total billed charges,,,95,,1.62,percent of total billed charges,,,60,,1.02,percent of total billed charges,,1.02,1.62,
XEROFORM 5X9 PETROLATUM DRESSING,102191,CDM,270,RC,,,,,Inpatient,,,1.7,,,,80,,1.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.32,percent of total billed charges,,,95,,1.62,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.62,
VASELINE GAUZE 3X18 CURAD,102192,CDM,270,RC,,,,,Outpatient,,,1.8,,,,80,,1.44,percent of total billed charges,,,,85,1.53,percent of total billed charges,,,77.7,,1.4,percent of total billed charges,,,95,,1.71,percent of total billed charges,,,60,,1.08,percent of total billed charges,,1.08,1.71,
VASELINE GAUZE 3X18 CURAD,102192,CDM,270,RC,,,,,Inpatient,,,1.8,,,,80,,1.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.4,percent of total billed charges,,,95,,1.71,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.71,
POLYP TRAP DUAL CHAMBER RUHOLF,102194,CDM,270,RC,,,,,Outpatient,,,17.4,,,,80,,13.92,percent of total billed charges,,,,85,14.79,percent of total billed charges,,,77.7,,13.52,percent of total billed charges,,,95,,16.53,percent of total billed charges,,,60,,10.44,percent of total billed charges,,10.44,16.53,
POLYP TRAP DUAL CHAMBER RUHOLF,102194,CDM,270,RC,,,,,Inpatient,,,17.4,,,,80,,13.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,13.52,percent of total billed charges,,,95,,16.53,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,16.53,
"THUNDERBEAT 5MM, 35CM FRONT",102195,CDM,270,RC,,,,,Outpatient,,,1645,,,,80,,1316,percent of total billed charges,,,,85,1398.25,percent of total billed charges,,,77.7,,1278.17,percent of total billed charges,,,95,,1562.75,percent of total billed charges,,,60,,987,percent of total billed charges,,987,1562.75,
"THUNDERBEAT 5MM, 35CM FRONT",102195,CDM,270,RC,,,,,Inpatient,,,1645,,,,80,,1316,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1278.17,percent of total billed charges,,,95,,1562.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1562.75,
OPTIFOAM 3X3 GENTLE SILICONE,102197,CDM,270,RC,,,,,Outpatient,,,6.6,,,,80,,5.28,percent of total billed charges,,,,85,5.61,percent of total billed charges,,,77.7,,5.13,percent of total billed charges,,,95,,6.27,percent of total billed charges,,,60,,3.96,percent of total billed charges,,3.96,6.27,
OPTIFOAM 3X3 GENTLE SILICONE,102197,CDM,270,RC,,,,,Inpatient,,,6.6,,,,80,,5.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.13,percent of total billed charges,,,95,,6.27,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.27,
INTUBATING 12FR STYLETTE,102198,CDM,270,RC,,,,,Outpatient,,,4.5,,,,80,,3.6,percent of total billed charges,,,,85,3.83,percent of total billed charges,,,77.7,,3.5,percent of total billed charges,,,95,,4.28,percent of total billed charges,,,60,,2.7,percent of total billed charges,,2.7,4.28,
INTUBATING 12FR STYLETTE,102198,CDM,270,RC,,,,,Inpatient,,,4.5,,,,80,,3.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.5,percent of total billed charges,,,95,,4.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.28,
SUTURE 0-Vicryl  J724D  OR,102204,CDM,270,RC,,,,,Outpatient,,,31.9,,,,80,,25.52,percent of total billed charges,,,,85,27.12,percent of total billed charges,,,77.7,,24.79,percent of total billed charges,,,95,,30.31,percent of total billed charges,,,60,,19.14,percent of total billed charges,,19.14,30.31,
SUTURE 0-Vicryl  J724D  OR,102204,CDM,270,RC,,,,,Inpatient,,,31.9,,,,80,,25.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,24.79,percent of total billed charges,,,95,,30.31,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,30.31,
SYNCHROMED REFILL KIT,102210,CDM,270,RC,,,,,Outpatient,,,70,,,,80,,56,percent of total billed charges,,,,85,59.5,percent of total billed charges,,,77.7,,54.39,percent of total billed charges,,,95,,66.5,percent of total billed charges,,,60,,42,percent of total billed charges,,42,66.5,
SYNCHROMED REFILL KIT,102210,CDM,270,RC,,,,,Inpatient,,,70,,,,80,,56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,54.39,percent of total billed charges,,,95,,66.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,66.5,
L3650 SLING MED COMMODE REUSABLE  HOYER,102220,CDM,274,RC,L3650,HCPCS,,,Outpatient,,,104.2,,,,80,,83.36,percent of total billed charges,,,,85,88.57,percent of total billed charges,,,77.7,,80.96,percent of total billed charges,,,95,,98.99,percent of total billed charges,,,60,,62.52,percent of total billed charges,,62.52,98.99,
L3650 SLING MED COMMODE REUSABLE  HOYER,102220,CDM,274,RC,L3650,HCPCS,,,Inpatient,,,104.2,,,,80,,83.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,80.96,percent of total billed charges,,,95,,98.99,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,98.99,
L3650 SLING LG COMMODE REUSABLE  HOYER,102221,CDM,274,RC,L3650,HCPCS,,,Outpatient,,,113.4,,,,80,,90.72,percent of total billed charges,,,,85,96.39,percent of total billed charges,,,77.7,,88.11,percent of total billed charges,,,95,,107.73,percent of total billed charges,,,60,,68.04,percent of total billed charges,,68.04,107.73,
L3650 SLING LG COMMODE REUSABLE  HOYER,102221,CDM,274,RC,L3650,HCPCS,,,Inpatient,,,113.4,,,,80,,90.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,88.11,percent of total billed charges,,,95,,107.73,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,107.73,
ADAPTER INLINE MDI,102223,CDM,270,RC,,,,,Outpatient,,,8.8,,,,80,,7.04,percent of total billed charges,,,,85,7.48,percent of total billed charges,,,77.7,,6.84,percent of total billed charges,,,95,,8.36,percent of total billed charges,,,60,,5.28,percent of total billed charges,,5.28,8.36,
ADAPTER INLINE MDI,102223,CDM,270,RC,,,,,Inpatient,,,8.8,,,,80,,7.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.84,percent of total billed charges,,,95,,8.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,8.36,
"HEMOVAC WOUND DRAIN 400CC 1/8""",102225,CDM,270,RC,,,,,Outpatient,,,31.5,,,,80,,25.2,percent of total billed charges,,,,85,26.78,percent of total billed charges,,,77.7,,24.48,percent of total billed charges,,,95,,29.93,percent of total billed charges,,,60,,18.9,percent of total billed charges,,18.9,29.93,
"HEMOVAC WOUND DRAIN 400CC 1/8""",102225,CDM,270,RC,,,,,Inpatient,,,31.5,,,,80,,25.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,24.48,percent of total billed charges,,,95,,29.93,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,29.93,
"HEMOVAC WOUND DRAIN 400CC 3/16""",102226,CDM,270,RC,,,,,Outpatient,,,34.2,,,,80,,27.36,percent of total billed charges,,,,85,29.07,percent of total billed charges,,,77.7,,26.57,percent of total billed charges,,,95,,32.49,percent of total billed charges,,,60,,20.52,percent of total billed charges,,20.52,32.49,
"HEMOVAC WOUND DRAIN 400CC 3/16""",102226,CDM,270,RC,,,,,Inpatient,,,34.2,,,,80,,27.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,26.57,percent of total billed charges,,,95,,32.49,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,32.49,
SPINAL/EPIDURAL DUAL NEEDLES 25x7.5,102227,CDM,270,RC,,,,,Outpatient,,,105.4,,,,80,,84.32,percent of total billed charges,,,,85,89.59,percent of total billed charges,,,77.7,,81.9,percent of total billed charges,,,95,,100.13,percent of total billed charges,,,60,,63.24,percent of total billed charges,,63.24,100.13,
SPINAL/EPIDURAL DUAL NEEDLES 25x7.5,102227,CDM,270,RC,,,,,Inpatient,,,105.4,,,,80,,84.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,81.9,percent of total billed charges,,,95,,100.13,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,100.13,
"ARM STRAP FOAM 1.5 X 32""",102228,CDM,270,RC,,,,,Outpatient,,,4.3,,,,80,,3.44,percent of total billed charges,,,,85,3.66,percent of total billed charges,,,77.7,,3.34,percent of total billed charges,,,95,,4.09,percent of total billed charges,,,60,,2.58,percent of total billed charges,,2.58,4.09,
"ARM STRAP FOAM 1.5 X 32""",102228,CDM,270,RC,,,,,Inpatient,,,4.3,,,,80,,3.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.34,percent of total billed charges,,,95,,4.09,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.09,
RESCUE NET,102240,CDM,270,RC,,,,,Outpatient,,,303.5,,,,80,,242.8,percent of total billed charges,,,,85,257.98,percent of total billed charges,,,77.7,,235.82,percent of total billed charges,,,95,,288.33,percent of total billed charges,,,60,,182.1,percent of total billed charges,,182.1,288.33,
RESCUE NET,102240,CDM,270,RC,,,,,Inpatient,,,303.5,,,,80,,242.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,235.82,percent of total billed charges,,,95,,288.33,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,288.33,
"NEEDLE SPINAL WHITACRE 22 X 5""",102241,CDM,270,RC,,,,,Outpatient,,,28,,,,80,,22.4,percent of total billed charges,,,,85,23.8,percent of total billed charges,,,77.7,,21.76,percent of total billed charges,,,95,,26.6,percent of total billed charges,,,60,,16.8,percent of total billed charges,,16.8,26.6,
"NEEDLE SPINAL WHITACRE 22 X 5""",102241,CDM,270,RC,,,,,Inpatient,,,28,,,,80,,22.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,21.76,percent of total billed charges,,,95,,26.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,26.6,
"NEEDLE SPINAL WHITACRE 25 X 5""",102242,CDM,270,RC,,,,,Outpatient,,,34.4,,,,80,,27.52,percent of total billed charges,,,,85,29.24,percent of total billed charges,,,77.7,,26.73,percent of total billed charges,,,95,,32.68,percent of total billed charges,,,60,,20.64,percent of total billed charges,,20.64,32.68,
"NEEDLE SPINAL WHITACRE 25 X 5""",102242,CDM,270,RC,,,,,Inpatient,,,34.4,,,,80,,27.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,26.73,percent of total billed charges,,,95,,32.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,32.68,
CATHETER STRAIGHT TIP 14FR,102243,CDM,270,RC,,,,,Outpatient,,,2,,,,80,,1.6,percent of total billed charges,,,,85,1.7,percent of total billed charges,,,77.7,,1.55,percent of total billed charges,,,95,,1.9,percent of total billed charges,,,60,,1.2,percent of total billed charges,,1.2,1.9,
CATHETER STRAIGHT TIP 14FR,102243,CDM,270,RC,,,,,Inpatient,,,2,,,,80,,1.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.55,percent of total billed charges,,,95,,1.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.9,
MEPILEX 3X3 DRESSING,102244,CDM,270,RC,,,,,Outpatient,,,8.1,,,,80,,6.48,percent of total billed charges,,,,85,6.89,percent of total billed charges,,,77.7,,6.29,percent of total billed charges,,,95,,7.7,percent of total billed charges,,,60,,4.86,percent of total billed charges,,4.86,7.7,
MEPILEX 3X3 DRESSING,102244,CDM,270,RC,,,,,Inpatient,,,8.1,,,,80,,6.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.29,percent of total billed charges,,,95,,7.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.7,
MEPILEX 5X6 DRESSING,102245,CDM,270,RC,,,,,Outpatient,,,17.9,,,,80,,14.32,percent of total billed charges,,,,85,15.22,percent of total billed charges,,,77.7,,13.91,percent of total billed charges,,,95,,17.01,percent of total billed charges,,,60,,10.74,percent of total billed charges,,10.74,17.01,
MEPILEX 5X6 DRESSING,102245,CDM,270,RC,,,,,Inpatient,,,17.9,,,,80,,14.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,13.91,percent of total billed charges,,,95,,17.01,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.01,
OPTIFOAM 3X3 DRESSING,102246,CDM,270,RC,,,,,Outpatient,,,6.7,,,,80,,5.36,percent of total billed charges,,,,85,5.7,percent of total billed charges,,,77.7,,5.21,percent of total billed charges,,,95,,6.37,percent of total billed charges,,,60,,4.02,percent of total billed charges,,4.02,6.37,
OPTIFOAM 3X3 DRESSING,102246,CDM,270,RC,,,,,Inpatient,,,6.7,,,,80,,5.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.21,percent of total billed charges,,,95,,6.37,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.37,
OPTIFOAM 7X7 DRESSING,102247,CDM,270,RC,,,,,Outpatient,,,19.8,,,,80,,15.84,percent of total billed charges,,,,85,16.83,percent of total billed charges,,,77.7,,15.38,percent of total billed charges,,,95,,18.81,percent of total billed charges,,,60,,11.88,percent of total billed charges,,11.88,18.81,
OPTIFOAM 7X7 DRESSING,102247,CDM,270,RC,,,,,Inpatient,,,19.8,,,,80,,15.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,15.38,percent of total billed charges,,,95,,18.81,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,18.81,
MEPILEX 6X8 DRESSING,102248,CDM,270,RC,,,,,Outpatient,,,17.4,,,,80,,13.92,percent of total billed charges,,,,85,14.79,percent of total billed charges,,,77.7,,13.52,percent of total billed charges,,,95,,16.53,percent of total billed charges,,,60,,10.44,percent of total billed charges,,10.44,16.53,
MEPILEX 6X8 DRESSING,102248,CDM,270,RC,,,,,Inpatient,,,17.4,,,,80,,13.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,13.52,percent of total billed charges,,,95,,16.53,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,16.53,
SUTURE 3-0 PERMA-HAND SILK K872H,102249,CDM,270,RC,,,,,Outpatient,,,4.7,,,,80,,3.76,percent of total billed charges,,,,85,4,percent of total billed charges,,,77.7,,3.65,percent of total billed charges,,,95,,4.47,percent of total billed charges,,,60,,2.82,percent of total billed charges,,2.82,4.47,
SUTURE 3-0 PERMA-HAND SILK K872H,102249,CDM,270,RC,,,,,Inpatient,,,4.7,,,,80,,3.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.65,percent of total billed charges,,,95,,4.47,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.47,
BORDERED GAUZE 4X4 DRESSING,102250,CDM,270,RC,,,,,Outpatient,,,1.6,,,,80,,1.28,percent of total billed charges,,,,85,1.36,percent of total billed charges,,,77.7,,1.24,percent of total billed charges,,,95,,1.52,percent of total billed charges,,,60,,0.96,percent of total billed charges,,0.96,1.52,
BORDERED GAUZE 4X4 DRESSING,102250,CDM,270,RC,,,,,Inpatient,,,1.6,,,,80,,1.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.24,percent of total billed charges,,,95,,1.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.52,
HME TRACH(BLUE),102251,CDM,270,RC,,,,,Outpatient,,,4.9,,,,80,,3.92,percent of total billed charges,,,,85,4.17,percent of total billed charges,,,77.7,,3.81,percent of total billed charges,,,95,,4.66,percent of total billed charges,,,60,,2.94,percent of total billed charges,,2.94,4.66,
HME TRACH(BLUE),102251,CDM,270,RC,,,,,Inpatient,,,4.9,,,,80,,3.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.81,percent of total billed charges,,,95,,4.66,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.66,
TRACH TUBE FLEXIBLE ADULT,102252,CDM,270,RC,,,,,Outpatient,,,239.6,,,,80,,191.68,percent of total billed charges,,,,85,203.66,percent of total billed charges,,,77.7,,186.17,percent of total billed charges,,,95,,227.62,percent of total billed charges,,,60,,143.76,percent of total billed charges,,143.76,227.62,
TRACH TUBE FLEXIBLE ADULT,102252,CDM,270,RC,,,,,Inpatient,,,239.6,,,,80,,191.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,186.17,percent of total billed charges,,,95,,227.62,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,227.62,
TRACH TUBE INNER CANNULA  SHILEY DISP,102253,CDM,270,RC,,,,,Outpatient,,,15,,,,80,,12,percent of total billed charges,,,,85,12.75,percent of total billed charges,,,77.7,,11.66,percent of total billed charges,,,95,,14.25,percent of total billed charges,,,60,,9,percent of total billed charges,,9,14.25,
TRACH TUBE INNER CANNULA  SHILEY DISP,102253,CDM,270,RC,,,,,Inpatient,,,15,,,,80,,12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.66,percent of total billed charges,,,95,,14.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,14.25,
MEPERIDINE PUMP,102306,CDM,270,RC,,,,,Outpatient,,,0.1,,,,80,,0.08,percent of total billed charges,,,,85,0.09,percent of total billed charges,,,77.7,,0.08,percent of total billed charges,,,95,,0.1,percent of total billed charges,,,60,,0.06,percent of total billed charges,,0.06,0.1,
MEPERIDINE PUMP,102306,CDM,270,RC,,,,,Inpatient,,,0.1,,,,80,,0.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.08,percent of total billed charges,,,95,,0.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,0.1,
BREATHING BAG - 1 LITER,102307,CDM,270,RC,,,,,Outpatient,,,7.2,,,,80,,5.76,percent of total billed charges,,,,85,6.12,percent of total billed charges,,,77.7,,5.59,percent of total billed charges,,,95,,6.84,percent of total billed charges,,,60,,4.32,percent of total billed charges,,4.32,6.84,
BREATHING BAG - 1 LITER,102307,CDM,270,RC,,,,,Inpatient,,,7.2,,,,80,,5.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.59,percent of total billed charges,,,95,,6.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.84,
INFANT AMBU BAG-DISP,102308,CDM,270,RC,,,,,Outpatient,,,106,,,,80,,84.8,percent of total billed charges,,,,85,90.1,percent of total billed charges,,,77.7,,82.36,percent of total billed charges,,,95,,100.7,percent of total billed charges,,,60,,63.6,percent of total billed charges,,63.6,100.7,
INFANT AMBU BAG-DISP,102308,CDM,270,RC,,,,,Inpatient,,,106,,,,80,,84.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,82.36,percent of total billed charges,,,95,,100.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,100.7,
UMBILICAL CATHETER 3.5FR,102309,CDM,270,RC,,,,,Outpatient,,,40.2,,,,80,,32.16,percent of total billed charges,,,,85,34.17,percent of total billed charges,,,77.7,,31.24,percent of total billed charges,,,95,,38.19,percent of total billed charges,,,60,,24.12,percent of total billed charges,,24.12,38.19,
UMBILICAL CATHETER 3.5FR,102309,CDM,270,RC,,,,,Inpatient,,,40.2,,,,80,,32.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,31.24,percent of total billed charges,,,95,,38.19,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,38.19,
INFANT O2 ELBOW,102310,CDM,270,RC,,,,,Outpatient,,,1.8,,,,80,,1.44,percent of total billed charges,,,,85,1.53,percent of total billed charges,,,77.7,,1.4,percent of total billed charges,,,95,,1.71,percent of total billed charges,,,60,,1.08,percent of total billed charges,,1.08,1.71,
INFANT O2 ELBOW,102310,CDM,270,RC,,,,,Inpatient,,,1.8,,,,80,,1.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.4,percent of total billed charges,,,95,,1.71,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.71,
INFANT FACE MASK,102311,CDM,270,RC,,,,,Outpatient,,,13.2,,,,80,,10.56,percent of total billed charges,,,,85,11.22,percent of total billed charges,,,77.7,,10.26,percent of total billed charges,,,95,,12.54,percent of total billed charges,,,60,,7.92,percent of total billed charges,,7.92,12.54,
INFANT FACE MASK,102311,CDM,270,RC,,,,,Inpatient,,,13.2,,,,80,,10.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.26,percent of total billed charges,,,95,,12.54,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,12.54,
ANESTHESIA MASK INFANT,102312,CDM,270,RC,,,,,Outpatient,,,15.1,,,,80,,12.08,percent of total billed charges,,,,85,12.84,percent of total billed charges,,,77.7,,11.73,percent of total billed charges,,,95,,14.35,percent of total billed charges,,,60,,9.06,percent of total billed charges,,9.06,14.35,
ANESTHESIA MASK INFANT,102312,CDM,270,RC,,,,,Inpatient,,,15.1,,,,80,,12.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.73,percent of total billed charges,,,95,,14.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,14.35,
TUBING ADAPTER 20G,102313,CDM,270,RC,,,,,Outpatient,,,1.9,,,,80,,1.52,percent of total billed charges,,,,85,1.62,percent of total billed charges,,,77.7,,1.48,percent of total billed charges,,,95,,1.81,percent of total billed charges,,,60,,1.14,percent of total billed charges,,1.14,1.81,
TUBING ADAPTER 20G,102313,CDM,270,RC,,,,,Inpatient,,,1.9,,,,80,,1.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.48,percent of total billed charges,,,95,,1.81,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.81,
T CONNECTOR,102314,CDM,270,RC,,,,,Outpatient,,,2.7,,,,80,,2.16,percent of total billed charges,,,,85,2.3,percent of total billed charges,,,77.7,,2.1,percent of total billed charges,,,95,,2.57,percent of total billed charges,,,60,,1.62,percent of total billed charges,,1.62,2.57,
T CONNECTOR,102314,CDM,270,RC,,,,,Inpatient,,,2.7,,,,80,,2.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.1,percent of total billed charges,,,95,,2.57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.57,
STOMACH TUBE NG 16 FR,102323,CDM,270,RC,,,,,Outpatient,,,3.5,,,,80,,2.8,percent of total billed charges,,,,85,2.98,percent of total billed charges,,,77.7,,2.72,percent of total billed charges,,,95,,3.33,percent of total billed charges,,,60,,2.1,percent of total billed charges,,2.1,3.33,
STOMACH TUBE NG 16 FR,102323,CDM,270,RC,,,,,Inpatient,,,3.5,,,,80,,2.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.72,percent of total billed charges,,,95,,3.33,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.33,
ENEMA SET,102327,CDM,270,RC,,,,,Outpatient,,,2.7,,,,80,,2.16,percent of total billed charges,,,,85,2.3,percent of total billed charges,,,77.7,,2.1,percent of total billed charges,,,95,,2.57,percent of total billed charges,,,60,,1.62,percent of total billed charges,,1.62,2.57,
ENEMA SET,102327,CDM,270,RC,,,,,Inpatient,,,2.7,,,,80,,2.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.1,percent of total billed charges,,,95,,2.57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.57,
STOMACH TUBE NG 18 FR,102328,CDM,270,RC,,,,,Outpatient,,,3.5,,,,80,,2.8,percent of total billed charges,,,,85,2.98,percent of total billed charges,,,77.7,,2.72,percent of total billed charges,,,95,,3.33,percent of total billed charges,,,60,,2.1,percent of total billed charges,,2.1,3.33,
STOMACH TUBE NG 18 FR,102328,CDM,270,RC,,,,,Inpatient,,,3.5,,,,80,,2.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.72,percent of total billed charges,,,95,,3.33,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.33,
FEEDING TUBE 5 FR 16 IN,102329,CDM,270,RC,,,,,Outpatient,,,3.4,,,,80,,2.72,percent of total billed charges,,,,85,2.89,percent of total billed charges,,,77.7,,2.64,percent of total billed charges,,,95,,3.23,percent of total billed charges,,,60,,2.04,percent of total billed charges,,2.04,3.23,
FEEDING TUBE 5 FR 16 IN,102329,CDM,270,RC,,,,,Inpatient,,,3.4,,,,80,,2.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.64,percent of total billed charges,,,95,,3.23,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.23,
SUCTION CATHETER 14 FR,102330,CDM,270,RC,,,,,Outpatient,,,2.3,,,,80,,1.84,percent of total billed charges,,,,85,1.96,percent of total billed charges,,,77.7,,1.79,percent of total billed charges,,,95,,2.19,percent of total billed charges,,,60,,1.38,percent of total billed charges,,1.38,2.19,
SUCTION CATHETER 14 FR,102330,CDM,270,RC,,,,,Inpatient,,,2.3,,,,80,,1.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.79,percent of total billed charges,,,95,,2.19,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.19,
SUCTION CATH 8FR,102331,CDM,270,RC,,,,,Outpatient,,,1.2,,,,80,,0.96,percent of total billed charges,,,,85,1.02,percent of total billed charges,,,77.7,,0.93,percent of total billed charges,,,95,,1.14,percent of total billed charges,,,60,,0.72,percent of total billed charges,,0.72,1.14,
SUCTION CATH 8FR,102331,CDM,270,RC,,,,,Inpatient,,,1.2,,,,80,,0.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.93,percent of total billed charges,,,95,,1.14,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.14,
SUCTION CATHETER 10FR,102332,CDM,270,RC,,,,,Outpatient,,,1.9,,,,80,,1.52,percent of total billed charges,,,,85,1.62,percent of total billed charges,,,77.7,,1.48,percent of total billed charges,,,95,,1.81,percent of total billed charges,,,60,,1.14,percent of total billed charges,,1.14,1.81,
SUCTION CATHETER 10FR,102332,CDM,270,RC,,,,,Inpatient,,,1.9,,,,80,,1.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.48,percent of total billed charges,,,95,,1.81,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.81,
LUMBAR PUNCTURE TRAY - ADULT,102333,CDM,270,RC,,,,,Outpatient,,,94.7,,,,80,,75.76,percent of total billed charges,,,,85,80.5,percent of total billed charges,,,77.7,,73.58,percent of total billed charges,,,95,,89.97,percent of total billed charges,,,60,,56.82,percent of total billed charges,,56.82,89.97,
LUMBAR PUNCTURE TRAY - ADULT,102333,CDM,270,RC,,,,,Inpatient,,,94.7,,,,80,,75.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,73.58,percent of total billed charges,,,95,,89.97,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,89.97,
THORACENTESIS TRAY,102341,CDM,270,RC,,,,,Outpatient,,,89.1,,,,80,,71.28,percent of total billed charges,,,,85,75.74,percent of total billed charges,,,77.7,,69.23,percent of total billed charges,,,95,,84.65,percent of total billed charges,,,60,,53.46,percent of total billed charges,,53.46,84.65,
THORACENTESIS TRAY,102341,CDM,270,RC,,,,,Inpatient,,,89.1,,,,80,,71.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,69.23,percent of total billed charges,,,95,,84.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,84.65,
ENDOTRACH TUBE 5.5 CUFFED,102342,CDM,270,RC,,,,,Outpatient,,,4.7,,,,80,,3.76,percent of total billed charges,,,,85,4,percent of total billed charges,,,77.7,,3.65,percent of total billed charges,,,95,,4.47,percent of total billed charges,,,60,,2.82,percent of total billed charges,,2.82,4.47,
ENDOTRACH TUBE 5.5 CUFFED,102342,CDM,270,RC,,,,,Inpatient,,,4.7,,,,80,,3.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.65,percent of total billed charges,,,95,,4.47,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.47,
ENDOTRACH TUBE 7.0 CUFFED,102343,CDM,270,RC,,,,,Outpatient,,,4.5,,,,80,,3.6,percent of total billed charges,,,,85,3.83,percent of total billed charges,,,77.7,,3.5,percent of total billed charges,,,95,,4.28,percent of total billed charges,,,60,,2.7,percent of total billed charges,,2.7,4.28,
ENDOTRACH TUBE 7.0 CUFFED,102343,CDM,270,RC,,,,,Inpatient,,,4.5,,,,80,,3.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.5,percent of total billed charges,,,95,,4.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.28,
ENDOTRACH TUBE 6.0 CUFFED,102344,CDM,270,RC,,,,,Outpatient,,,4.7,,,,80,,3.76,percent of total billed charges,,,,85,4,percent of total billed charges,,,77.7,,3.65,percent of total billed charges,,,95,,4.47,percent of total billed charges,,,60,,2.82,percent of total billed charges,,2.82,4.47,
ENDOTRACH TUBE 6.0 CUFFED,102344,CDM,270,RC,,,,,Inpatient,,,4.7,,,,80,,3.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.65,percent of total billed charges,,,95,,4.47,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.47,
ENDOTRACH TUBE 6.5 CUFFED,102345,CDM,270,RC,,,,,Outpatient,,,4.7,,,,80,,3.76,percent of total billed charges,,,,85,4,percent of total billed charges,,,77.7,,3.65,percent of total billed charges,,,95,,4.47,percent of total billed charges,,,60,,2.82,percent of total billed charges,,2.82,4.47,
ENDOTRACH TUBE 6.5 CUFFED,102345,CDM,270,RC,,,,,Inpatient,,,4.7,,,,80,,3.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.65,percent of total billed charges,,,95,,4.47,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.47,
ENDOTRACH TUBE 8.0,102346,CDM,270,RC,,,,,Outpatient,,,4.5,,,,80,,3.6,percent of total billed charges,,,,85,3.83,percent of total billed charges,,,77.7,,3.5,percent of total billed charges,,,95,,4.28,percent of total billed charges,,,60,,2.7,percent of total billed charges,,2.7,4.28,
ENDOTRACH TUBE 8.0,102346,CDM,270,RC,,,,,Inpatient,,,4.5,,,,80,,3.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.5,percent of total billed charges,,,95,,4.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.28,
ENDOTRACH TUBE 9.0,102347,CDM,270,RC,,,,,Outpatient,,,6.6,,,,80,,5.28,percent of total billed charges,,,,85,5.61,percent of total billed charges,,,77.7,,5.13,percent of total billed charges,,,95,,6.27,percent of total billed charges,,,60,,3.96,percent of total billed charges,,3.96,6.27,
ENDOTRACH TUBE 9.0,102347,CDM,270,RC,,,,,Inpatient,,,6.6,,,,80,,5.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.13,percent of total billed charges,,,95,,6.27,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.27,
ENDOTRACH TUBE 3.0 UNCUFFED,102348,CDM,270,RC,,,,,Outpatient,,,3.8,,,,80,,3.04,percent of total billed charges,,,,85,3.23,percent of total billed charges,,,77.7,,2.95,percent of total billed charges,,,95,,3.61,percent of total billed charges,,,60,,2.28,percent of total billed charges,,2.28,3.61,
ENDOTRACH TUBE 3.0 UNCUFFED,102348,CDM,270,RC,,,,,Inpatient,,,3.8,,,,80,,3.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.95,percent of total billed charges,,,95,,3.61,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.61,
ENDOTRACH TUBE 5.0 CUFFED,102349,CDM,270,RC,,,,,Outpatient,,,5.9,,,,80,,4.72,percent of total billed charges,,,,85,5.02,percent of total billed charges,,,77.7,,4.58,percent of total billed charges,,,95,,5.61,percent of total billed charges,,,60,,3.54,percent of total billed charges,,3.54,5.61,
ENDOTRACH TUBE 5.0 CUFFED,102349,CDM,270,RC,,,,,Inpatient,,,5.9,,,,80,,4.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.58,percent of total billed charges,,,95,,5.61,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.61,
ENDOTRACH TUBE 8.5,102350,CDM,270,RC,,,,,Outpatient,,,5.7,,,,80,,4.56,percent of total billed charges,,,,85,4.85,percent of total billed charges,,,77.7,,4.43,percent of total billed charges,,,95,,5.42,percent of total billed charges,,,60,,3.42,percent of total billed charges,,3.42,5.42,
ENDOTRACH TUBE 8.5,102350,CDM,270,RC,,,,,Inpatient,,,5.7,,,,80,,4.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.43,percent of total billed charges,,,95,,5.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.42,
ENDOTRACH TUBE 4.5 CUFFED,102351,CDM,270,RC,,,,,Outpatient,,,4.7,,,,80,,3.76,percent of total billed charges,,,,85,4,percent of total billed charges,,,77.7,,3.65,percent of total billed charges,,,95,,4.47,percent of total billed charges,,,60,,2.82,percent of total billed charges,,2.82,4.47,
ENDOTRACH TUBE 4.5 CUFFED,102351,CDM,270,RC,,,,,Inpatient,,,4.7,,,,80,,3.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.65,percent of total billed charges,,,95,,4.47,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.47,
ENDOTRACH TUBE 2.5 UNCUFFED,102353,CDM,270,RC,,,,,Outpatient,,,2.9,,,,80,,2.32,percent of total billed charges,,,,85,2.47,percent of total billed charges,,,77.7,,2.25,percent of total billed charges,,,95,,2.76,percent of total billed charges,,,60,,1.74,percent of total billed charges,,1.74,2.76,
ENDOTRACH TUBE 2.5 UNCUFFED,102353,CDM,270,RC,,,,,Inpatient,,,2.9,,,,80,,2.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.25,percent of total billed charges,,,95,,2.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.76,
INTRAOSSEOUS NEEDLE 18G,102358,CDM,270,RC,,,,,Outpatient,,,46.3,,,,80,,37.04,percent of total billed charges,,,,85,39.36,percent of total billed charges,,,77.7,,35.98,percent of total billed charges,,,95,,43.99,percent of total billed charges,,,60,,27.78,percent of total billed charges,,27.78,43.99,
INTRAOSSEOUS NEEDLE 18G,102358,CDM,270,RC,,,,,Inpatient,,,46.3,,,,80,,37.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,35.98,percent of total billed charges,,,95,,43.99,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,43.99,
NEEDLE SPINAL WHITACRE 22 X 3 1/2,102369,CDM,270,RC,,,,,Outpatient,,,33.3,,,,80,,26.64,percent of total billed charges,,,,85,28.31,percent of total billed charges,,,77.7,,25.87,percent of total billed charges,,,95,,31.64,percent of total billed charges,,,60,,19.98,percent of total billed charges,,19.98,31.64,
NEEDLE SPINAL WHITACRE 22 X 3 1/2,102369,CDM,270,RC,,,,,Inpatient,,,33.3,,,,80,,26.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,25.87,percent of total billed charges,,,95,,31.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,31.64,
MEDIPORE W/PAD 3.5 X 8,102381,CDM,270,RC,,,,,Outpatient,,,3,,,,80,,2.4,percent of total billed charges,,,,85,2.55,percent of total billed charges,,,77.7,,2.33,percent of total billed charges,,,95,,2.85,percent of total billed charges,,,60,,1.8,percent of total billed charges,,1.8,2.85,
MEDIPORE W/PAD 3.5 X 8,102381,CDM,270,RC,,,,,Inpatient,,,3,,,,80,,2.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.33,percent of total billed charges,,,95,,2.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.85,
SURGI PADS ABD 5X9,102385,CDM,270,RC,,,,,Outpatient,,,0.5,,,,80,,0.4,percent of total billed charges,,,,85,0.43,percent of total billed charges,,,77.7,,0.39,percent of total billed charges,,,95,,0.48,percent of total billed charges,,,60,,0.3,percent of total billed charges,,0.3,0.48,
SURGI PADS ABD 5X9,102385,CDM,270,RC,,,,,Inpatient,,,0.5,,,,80,,0.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.39,percent of total billed charges,,,95,,0.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,0.48,
GAUZE SPONGE 4X4 PK STERILE,102388,CDM,270,RC,,,,,Outpatient,,,0.5,,,,80,,0.4,percent of total billed charges,,,,85,0.43,percent of total billed charges,,,77.7,,0.39,percent of total billed charges,,,95,,0.48,percent of total billed charges,,,60,,0.3,percent of total billed charges,,0.3,0.48,
GAUZE SPONGE 4X4 PK STERILE,102388,CDM,270,RC,,,,,Inpatient,,,0.5,,,,80,,0.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.39,percent of total billed charges,,,95,,0.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,0.48,
"KERLIX SMALL BANDAGE ROLL 2""",102390,CDM,270,RC,,,,,Outpatient,,,1,,,,80,,0.8,percent of total billed charges,,,,85,0.85,percent of total billed charges,,,77.7,,0.78,percent of total billed charges,,,95,,0.95,percent of total billed charges,,,60,,0.6,percent of total billed charges,,0.6,0.95,
"KERLIX SMALL BANDAGE ROLL 2""",102390,CDM,270,RC,,,,,Inpatient,,,1,,,,80,,0.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.78,percent of total billed charges,,,95,,0.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,0.95,
CONFORMING DRESSING ROLL,102391,CDM,270,RC,,,,,Outpatient,,,1.6,,,,80,,1.28,percent of total billed charges,,,,85,1.36,percent of total billed charges,,,77.7,,1.24,percent of total billed charges,,,95,,1.52,percent of total billed charges,,,60,,0.96,percent of total billed charges,,0.96,1.52,
CONFORMING DRESSING ROLL,102391,CDM,270,RC,,,,,Inpatient,,,1.6,,,,80,,1.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.24,percent of total billed charges,,,95,,1.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.52,
"KLING 2""",102392,CDM,270,RC,,,,,Outpatient,,,1.3,,,,80,,1.04,percent of total billed charges,,,,85,1.11,percent of total billed charges,,,77.7,,1.01,percent of total billed charges,,,95,,1.24,percent of total billed charges,,,60,,0.78,percent of total billed charges,,0.78,1.24,
"KLING 2""",102392,CDM,270,RC,,,,,Inpatient,,,1.3,,,,80,,1.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.01,percent of total billed charges,,,95,,1.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.24,
"KLING 6""",102393,CDM,270,RC,,,,,Outpatient,,,1.7,,,,80,,1.36,percent of total billed charges,,,,85,1.45,percent of total billed charges,,,77.7,,1.32,percent of total billed charges,,,95,,1.62,percent of total billed charges,,,60,,1.02,percent of total billed charges,,1.02,1.62,
"KLING 6""",102393,CDM,270,RC,,,,,Inpatient,,,1.7,,,,80,,1.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.32,percent of total billed charges,,,95,,1.62,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.62,
"ACE BANDAGE 4""",102408,CDM,270,RC,,,,,Outpatient,,,4.8,,,,80,,3.84,percent of total billed charges,,,,85,4.08,percent of total billed charges,,,77.7,,3.73,percent of total billed charges,,,95,,4.56,percent of total billed charges,,,60,,2.88,percent of total billed charges,,2.88,4.56,
"ACE BANDAGE 4""",102408,CDM,270,RC,,,,,Inpatient,,,4.8,,,,80,,3.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.73,percent of total billed charges,,,95,,4.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.56,
"ELASTOPLAST 2""",102409,CDM,270,RC,,,,,Outpatient,,,10.3,,,,80,,8.24,percent of total billed charges,,,,85,8.76,percent of total billed charges,,,77.7,,8,percent of total billed charges,,,95,,9.79,percent of total billed charges,,,60,,6.18,percent of total billed charges,,6.18,9.79,
"ELASTOPLAST 2""",102409,CDM,270,RC,,,,,Inpatient,,,10.3,,,,80,,8.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8,percent of total billed charges,,,95,,9.79,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.79,
Cannula Nasal Adult 7'',102410,CDM,270,RC,,,,,Outpatient,,,1.4,,,,80,,1.12,percent of total billed charges,,,,85,1.19,percent of total billed charges,,,77.7,,1.09,percent of total billed charges,,,95,,1.33,percent of total billed charges,,,60,,0.84,percent of total billed charges,,0.84,1.33,
Cannula Nasal Adult 7'',102410,CDM,270,RC,,,,,Inpatient,,,1.4,,,,80,,1.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.09,percent of total billed charges,,,95,,1.33,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.33,
EPISTICK,102414,CDM,270,RC,,,,,Outpatient,,,2.3,,,,80,,1.84,percent of total billed charges,,,,85,1.96,percent of total billed charges,,,77.7,,1.79,percent of total billed charges,,,95,,2.19,percent of total billed charges,,,60,,1.38,percent of total billed charges,,1.38,2.19,
EPISTICK,102414,CDM,270,RC,,,,,Inpatient,,,2.3,,,,80,,1.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.79,percent of total billed charges,,,95,,2.19,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.19,
BULB SYRINGE,102418,CDM,270,RC,,,,,Outpatient,,,2,,,,80,,1.6,percent of total billed charges,,,,85,1.7,percent of total billed charges,,,77.7,,1.55,percent of total billed charges,,,95,,1.9,percent of total billed charges,,,60,,1.2,percent of total billed charges,,1.2,1.9,
BULB SYRINGE,102418,CDM,270,RC,,,,,Inpatient,,,2,,,,80,,1.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.55,percent of total billed charges,,,95,,1.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.9,
SHAVE PREP,102419,CDM,270,RC,,,,,Outpatient,,,8.9,,,,80,,7.12,percent of total billed charges,,,,85,7.57,percent of total billed charges,,,77.7,,6.92,percent of total billed charges,,,95,,8.46,percent of total billed charges,,,60,,5.34,percent of total billed charges,,5.34,8.46,
SHAVE PREP,102419,CDM,270,RC,,,,,Inpatient,,,8.9,,,,80,,7.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.92,percent of total billed charges,,,95,,8.46,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,8.46,
AIRWAY ORAL 90MM YELLOW,102421,CDM,270,RC,,,,,Outpatient,,,0.8,,,,80,,0.64,percent of total billed charges,,,,85,0.68,percent of total billed charges,,,77.7,,0.62,percent of total billed charges,,,95,,0.76,percent of total billed charges,,,60,,0.48,percent of total billed charges,,0.48,0.76,
AIRWAY ORAL 90MM YELLOW,102421,CDM,270,RC,,,,,Inpatient,,,0.8,,,,80,,0.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.62,percent of total billed charges,,,95,,0.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,0.76,
AIRWAY ORAL INFANT,102422,CDM,270,RC,,,,,Outpatient,,,0.4,,,,80,,0.32,percent of total billed charges,,,,85,0.34,percent of total billed charges,,,77.7,,0.31,percent of total billed charges,,,95,,0.38,percent of total billed charges,,,60,,0.24,percent of total billed charges,,0.24,0.38,
AIRWAY ORAL INFANT,102422,CDM,270,RC,,,,,Inpatient,,,0.4,,,,80,,0.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.31,percent of total billed charges,,,95,,0.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,0.38,
PENROSE DRAIN 1/2 X 18,102433,CDM,270,RC,,,,,Outpatient,,,5.5,,,,80,,4.4,percent of total billed charges,,,,85,4.68,percent of total billed charges,,,77.7,,4.27,percent of total billed charges,,,95,,5.23,percent of total billed charges,,,60,,3.3,percent of total billed charges,,3.3,5.23,
PENROSE DRAIN 1/2 X 18,102433,CDM,270,RC,,,,,Inpatient,,,5.5,,,,80,,4.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.27,percent of total billed charges,,,95,,5.23,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.23,
PENROSE DRAIN 1/2 X 12,102434,CDM,270,RC,,,,,Outpatient,,,3.5,,,,80,,2.8,percent of total billed charges,,,,85,2.98,percent of total billed charges,,,77.7,,2.72,percent of total billed charges,,,95,,3.33,percent of total billed charges,,,60,,2.1,percent of total billed charges,,2.1,3.33,
PENROSE DRAIN 1/2 X 12,102434,CDM,270,RC,,,,,Inpatient,,,3.5,,,,80,,2.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.72,percent of total billed charges,,,95,,3.33,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.33,
O2 MASK WITH TUBING,102440,CDM,270,RC,,,,,Outpatient,,,2.2,,,,80,,1.76,percent of total billed charges,,,,85,1.87,percent of total billed charges,,,77.7,,1.71,percent of total billed charges,,,95,,2.09,percent of total billed charges,,,60,,1.32,percent of total billed charges,,1.32,2.09,
O2 MASK WITH TUBING,102440,CDM,270,RC,,,,,Inpatient,,,2.2,,,,80,,1.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.71,percent of total billed charges,,,95,,2.09,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.09,
RING CUSHION,102441,CDM,270,RC,,,,,Outpatient,,,14.7,,,,80,,11.76,percent of total billed charges,,,,85,12.5,percent of total billed charges,,,77.7,,11.42,percent of total billed charges,,,95,,13.97,percent of total billed charges,,,60,,8.82,percent of total billed charges,,8.82,13.97,
RING CUSHION,102441,CDM,270,RC,,,,,Inpatient,,,14.7,,,,80,,11.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.42,percent of total billed charges,,,95,,13.97,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.97,
URETHRAL CATH KIT 15 FR LATEX,102442,CDM,270,RC,,,,,Outpatient,,,8.1,,,,80,,6.48,percent of total billed charges,,,,85,6.89,percent of total billed charges,,,77.7,,6.29,percent of total billed charges,,,95,,7.7,percent of total billed charges,,,60,,4.86,percent of total billed charges,,4.86,7.7,
URETHRAL CATH KIT 15 FR LATEX,102442,CDM,270,RC,,,,,Inpatient,,,8.1,,,,80,,6.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.29,percent of total billed charges,,,95,,7.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.7,
150ml Burette set (SOLUSET),102443,CDM,270,RC,,,,,Outpatient,,,11.4,,,,80,,9.12,percent of total billed charges,,,,85,9.69,percent of total billed charges,,,77.7,,8.86,percent of total billed charges,,,95,,10.83,percent of total billed charges,,,60,,6.84,percent of total billed charges,,6.84,10.83,
150ml Burette set (SOLUSET),102443,CDM,270,RC,,,,,Inpatient,,,11.4,,,,80,,9.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.86,percent of total billed charges,,,95,,10.83,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.83,
ZZZIPPB CIRCUIT,102451,CDM,270,RC,,,,,Outpatient,,,9.8,,,,80,,7.84,percent of total billed charges,,,,85,8.33,percent of total billed charges,,,77.7,,7.61,percent of total billed charges,,,95,,9.31,percent of total billed charges,,,60,,5.88,percent of total billed charges,,5.88,9.31,
ZZZIPPB CIRCUIT,102451,CDM,270,RC,,,,,Inpatient,,,9.8,,,,80,,7.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.61,percent of total billed charges,,,95,,9.31,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.31,
CATHETER BAGS,102452,CDM,270,RC,,,,,Outpatient,,,18.7,,,,80,,14.96,percent of total billed charges,,,,85,15.9,percent of total billed charges,,,77.7,,14.53,percent of total billed charges,,,95,,17.77,percent of total billed charges,,,60,,11.22,percent of total billed charges,,11.22,17.77,
CATHETER BAGS,102452,CDM,270,RC,,,,,Inpatient,,,18.7,,,,80,,14.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.53,percent of total billed charges,,,95,,17.77,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.77,
ALCOHOL LIQUID 16 0Z,102454,CDM,270,RC,,,,,Outpatient,,,0.8,,,,80,,0.64,percent of total billed charges,,,,85,0.68,percent of total billed charges,,,77.7,,0.62,percent of total billed charges,,,95,,0.76,percent of total billed charges,,,60,,0.48,percent of total billed charges,,0.48,0.76,
ALCOHOL LIQUID 16 0Z,102454,CDM,270,RC,,,,,Inpatient,,,0.8,,,,80,,0.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.62,percent of total billed charges,,,95,,0.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,0.76,
STOPCOK 3-WAY SWIVEL MALE LUER LOCK,102455,CDM,270,RC,,,,,Outpatient,,,1.6,,,,80,,1.28,percent of total billed charges,,,,85,1.36,percent of total billed charges,,,77.7,,1.24,percent of total billed charges,,,95,,1.52,percent of total billed charges,,,60,,0.96,percent of total billed charges,,0.96,1.52,
STOPCOK 3-WAY SWIVEL MALE LUER LOCK,102455,CDM,270,RC,,,,,Inpatient,,,1.6,,,,80,,1.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.24,percent of total billed charges,,,95,,1.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.52,
NEBULIZER,102457,CDM,270,RC,,,,,Outpatient,,,6.7,,,,80,,5.36,percent of total billed charges,,,,85,5.7,percent of total billed charges,,,77.7,,5.21,percent of total billed charges,,,95,,6.37,percent of total billed charges,,,60,,4.02,percent of total billed charges,,4.02,6.37,
NEBULIZER,102457,CDM,270,RC,,,,,Inpatient,,,6.7,,,,80,,5.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.21,percent of total billed charges,,,95,,6.37,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.37,
BARDPARKER HUMIDIFIER,102458,CDM,270,RC,,,,,Outpatient,,,9.1,,,,80,,7.28,percent of total billed charges,,,,85,7.74,percent of total billed charges,,,77.7,,7.07,percent of total billed charges,,,95,,8.65,percent of total billed charges,,,60,,5.46,percent of total billed charges,,5.46,8.65,
BARDPARKER HUMIDIFIER,102458,CDM,270,RC,,,,,Inpatient,,,9.1,,,,80,,7.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.07,percent of total billed charges,,,95,,8.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,8.65,
IV PUMP LINE W/SECURE LOCK,102461,CDM,270,RC,,,,,Outpatient,,,17.5,,,,80,,14,percent of total billed charges,,,,85,14.88,percent of total billed charges,,,77.7,,13.6,percent of total billed charges,,,95,,16.63,percent of total billed charges,,,60,,10.5,percent of total billed charges,,10.5,16.63,
IV PUMP LINE W/SECURE LOCK,102461,CDM,270,RC,,,,,Inpatient,,,17.5,,,,80,,14,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,13.6,percent of total billed charges,,,95,,16.63,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,16.63,
NITRO PUMP LINE,102465,CDM,270,RC,,,,,Outpatient,,,212.2,,,,80,,169.76,percent of total billed charges,,,,85,180.37,percent of total billed charges,,,77.7,,164.88,percent of total billed charges,,,95,,201.59,percent of total billed charges,,,60,,127.32,percent of total billed charges,,127.32,201.59,
NITRO PUMP LINE,102465,CDM,270,RC,,,,,Inpatient,,,212.2,,,,80,,169.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,164.88,percent of total billed charges,,,95,,201.59,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,201.59,
NIPPLE SHIELD SMALL STERILE,102470,CDM,270,RC,,,,,Outpatient,,,13.9,,,,80,,11.12,percent of total billed charges,,,,85,11.82,percent of total billed charges,,,77.7,,10.8,percent of total billed charges,,,95,,13.21,percent of total billed charges,,,60,,8.34,percent of total billed charges,,8.34,13.21,
NIPPLE SHIELD SMALL STERILE,102470,CDM,270,RC,,,,,Inpatient,,,13.9,,,,80,,11.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.8,percent of total billed charges,,,95,,13.21,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.21,
TRIGRADUATE,102479,CDM,270,RC,,,,,Outpatient,,,1,,,,80,,0.8,percent of total billed charges,,,,85,0.85,percent of total billed charges,,,77.7,,0.78,percent of total billed charges,,,95,,0.95,percent of total billed charges,,,60,,0.6,percent of total billed charges,,0.6,0.95,
TRIGRADUATE,102479,CDM,270,RC,,,,,Inpatient,,,1,,,,80,,0.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.78,percent of total billed charges,,,95,,0.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,0.95,
L0120 CERVICAL COLLAR-MED,102480,CDM,274,RC,L0120,HCPCS,,,Outpatient,,,11.5,,,,80,,9.2,percent of total billed charges,,,,85,9.78,percent of total billed charges,,,77.7,,8.94,percent of total billed charges,,,95,,10.93,percent of total billed charges,,,60,,6.9,percent of total billed charges,,6.9,10.93,
L0120 CERVICAL COLLAR-MED,102480,CDM,274,RC,L0120,HCPCS,,,Inpatient,,,11.5,,,,80,,9.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.94,percent of total billed charges,,,95,,10.93,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.93,
L3260 HEALING SHOE LARGE,102482,CDM,274,RC,L3260,HCPCS,,,Outpatient,,,18.3,,,,80,,14.64,percent of total billed charges,,,,85,15.56,percent of total billed charges,,,77.7,,14.22,percent of total billed charges,,,95,,17.39,percent of total billed charges,,,60,,10.98,percent of total billed charges,,10.98,17.39,
L3260 HEALING SHOE LARGE,102482,CDM,274,RC,L3260,HCPCS,,,Inpatient,,,18.3,,,,80,,14.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.22,percent of total billed charges,,,95,,17.39,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.39,
DELEE TRAP,102484,CDM,270,RC,,,,,Outpatient,,,10.1,,,,80,,8.08,percent of total billed charges,,,,85,8.59,percent of total billed charges,,,77.7,,7.85,percent of total billed charges,,,95,,9.6,percent of total billed charges,,,60,,6.06,percent of total billed charges,,6.06,9.6,
DELEE TRAP,102484,CDM,270,RC,,,,,Inpatient,,,10.1,,,,80,,8.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.85,percent of total billed charges,,,95,,9.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.6,
VENTI MASK-ADULT,102485,CDM,270,RC,,,,,Outpatient,,,5.9,,,,80,,4.72,percent of total billed charges,,,,85,5.02,percent of total billed charges,,,77.7,,4.58,percent of total billed charges,,,95,,5.61,percent of total billed charges,,,60,,3.54,percent of total billed charges,,3.54,5.61,
VENTI MASK-ADULT,102485,CDM,270,RC,,,,,Inpatient,,,5.9,,,,80,,4.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.58,percent of total billed charges,,,95,,5.61,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.61,
OXYGEN TENT,102486,CDM,270,RC,,,,,Outpatient,,,39.2,,,,80,,31.36,percent of total billed charges,,,,85,33.32,percent of total billed charges,,,77.7,,30.46,percent of total billed charges,,,95,,37.24,percent of total billed charges,,,60,,23.52,percent of total billed charges,,23.52,37.24,
OXYGEN TENT,102486,CDM,270,RC,,,,,Inpatient,,,39.2,,,,80,,31.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,30.46,percent of total billed charges,,,95,,37.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,37.24,
K66 SUCTION TUBE,102488,CDM,270,RC,,,,,Outpatient,,,1.9,,,,80,,1.52,percent of total billed charges,,,,85,1.62,percent of total billed charges,,,77.7,,1.48,percent of total billed charges,,,95,,1.81,percent of total billed charges,,,60,,1.14,percent of total billed charges,,1.14,1.81,
K66 SUCTION TUBE,102488,CDM,270,RC,,,,,Inpatient,,,1.9,,,,80,,1.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.48,percent of total billed charges,,,95,,1.81,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.81,
BUBBLE HUMIDIFIER,102489,CDM,270,RC,,,,,Outpatient,,,6.1,,,,80,,4.88,percent of total billed charges,,,,85,5.19,percent of total billed charges,,,77.7,,4.74,percent of total billed charges,,,95,,5.8,percent of total billed charges,,,60,,3.66,percent of total billed charges,,3.66,5.8,
BUBBLE HUMIDIFIER,102489,CDM,270,RC,,,,,Inpatient,,,6.1,,,,80,,4.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.74,percent of total billed charges,,,95,,5.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.8,
HUMIDIFIER COOL MIST,102491,CDM,270,RC,,,,,Outpatient,,,9.1,,,,80,,7.28,percent of total billed charges,,,,85,7.74,percent of total billed charges,,,77.7,,7.07,percent of total billed charges,,,95,,8.65,percent of total billed charges,,,60,,5.46,percent of total billed charges,,5.46,8.65,
HUMIDIFIER COOL MIST,102491,CDM,270,RC,,,,,Inpatient,,,9.1,,,,80,,7.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.07,percent of total billed charges,,,95,,8.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,8.65,
SPIROMETER,102493,CDM,270,RC,,,,,Outpatient,,,6.8,,,,80,,5.44,percent of total billed charges,,,,85,5.78,percent of total billed charges,,,77.7,,5.28,percent of total billed charges,,,95,,6.46,percent of total billed charges,,,60,,4.08,percent of total billed charges,,4.08,6.46,
SPIROMETER,102493,CDM,270,RC,,,,,Inpatient,,,6.8,,,,80,,5.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.28,percent of total billed charges,,,95,,6.46,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.46,
PEAK FLOW METER,102494,CDM,270,RC,,,,,Outpatient,,,36.1,,,,80,,28.88,percent of total billed charges,,,,85,30.69,percent of total billed charges,,,77.7,,28.05,percent of total billed charges,,,95,,34.3,percent of total billed charges,,,60,,21.66,percent of total billed charges,,21.66,34.3,
PEAK FLOW METER,102494,CDM,270,RC,,,,,Inpatient,,,36.1,,,,80,,28.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,28.05,percent of total billed charges,,,95,,34.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,34.3,
ADULT NONREBREATHING MASK,102495,CDM,270,RC,,,,,Outpatient,,,3.5,,,,80,,2.8,percent of total billed charges,,,,85,2.98,percent of total billed charges,,,77.7,,2.72,percent of total billed charges,,,95,,3.33,percent of total billed charges,,,60,,2.1,percent of total billed charges,,2.1,3.33,
ADULT NONREBREATHING MASK,102495,CDM,270,RC,,,,,Inpatient,,,3.5,,,,80,,2.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.72,percent of total billed charges,,,95,,3.33,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.33,
PED NONREBREATHING MASK,102496,CDM,270,RC,,,,,Outpatient,,,3.9,,,,80,,3.12,percent of total billed charges,,,,85,3.32,percent of total billed charges,,,77.7,,3.03,percent of total billed charges,,,95,,3.71,percent of total billed charges,,,60,,2.34,percent of total billed charges,,2.34,3.71,
PED NONREBREATHING MASK,102496,CDM,270,RC,,,,,Inpatient,,,3.9,,,,80,,3.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.03,percent of total billed charges,,,95,,3.71,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.71,
COMFORT 02 MASK,102497,CDM,270,RC,,,,,Outpatient,,,9.6,,,,80,,7.68,percent of total billed charges,,,,85,8.16,percent of total billed charges,,,77.7,,7.46,percent of total billed charges,,,95,,9.12,percent of total billed charges,,,60,,5.76,percent of total billed charges,,5.76,9.12,
COMFORT 02 MASK,102497,CDM,270,RC,,,,,Inpatient,,,9.6,,,,80,,7.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.46,percent of total billed charges,,,95,,9.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.12,
SUCTION CATHETER 14F W/G,102498,CDM,270,RC,,,,,Outpatient,,,2.4,,,,80,,1.92,percent of total billed charges,,,,85,2.04,percent of total billed charges,,,77.7,,1.86,percent of total billed charges,,,95,,2.28,percent of total billed charges,,,60,,1.44,percent of total billed charges,,1.44,2.28,
SUCTION CATHETER 14F W/G,102498,CDM,270,RC,,,,,Inpatient,,,2.4,,,,80,,1.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.86,percent of total billed charges,,,95,,2.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.28,
ANESTHESIA MASK-LG,102499,CDM,270,RC,,,,,Outpatient,,,5.9,,,,80,,4.72,percent of total billed charges,,,,85,5.02,percent of total billed charges,,,77.7,,4.58,percent of total billed charges,,,95,,5.61,percent of total billed charges,,,60,,3.54,percent of total billed charges,,3.54,5.61,
ANESTHESIA MASK-LG,102499,CDM,270,RC,,,,,Inpatient,,,5.9,,,,80,,4.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.58,percent of total billed charges,,,95,,5.61,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.61,
SUCTION CATHETER 14F W CONTROL,102500,CDM,270,RC,,,,,Outpatient,,,0.3,,,,80,,0.24,percent of total billed charges,,,,85,0.26,percent of total billed charges,,,77.7,,0.23,percent of total billed charges,,,95,,0.29,percent of total billed charges,,,60,,0.18,percent of total billed charges,,0.18,0.29,
SUCTION CATHETER 14F W CONTROL,102500,CDM,270,RC,,,,,Inpatient,,,0.3,,,,80,,0.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.23,percent of total billed charges,,,95,,0.29,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,0.29,
STOMACH TUBE NG 28 FR,102501,CDM,270,RC,,,,,Outpatient,,,33.5,,,,80,,26.8,percent of total billed charges,,,,85,28.48,percent of total billed charges,,,77.7,,26.03,percent of total billed charges,,,95,,31.83,percent of total billed charges,,,60,,20.1,percent of total billed charges,,20.1,31.83,
STOMACH TUBE NG 28 FR,102501,CDM,270,RC,,,,,Inpatient,,,33.5,,,,80,,26.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,26.03,percent of total billed charges,,,95,,31.83,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,31.83,
SUCTION CATH 10F W CONTROL,102502,CDM,270,RC,,,,,Outpatient,,,1.4,,,,80,,1.12,percent of total billed charges,,,,85,1.19,percent of total billed charges,,,77.7,,1.09,percent of total billed charges,,,95,,1.33,percent of total billed charges,,,60,,0.84,percent of total billed charges,,0.84,1.33,
SUCTION CATH 10F W CONTROL,102502,CDM,270,RC,,,,,Inpatient,,,1.4,,,,80,,1.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.09,percent of total billed charges,,,95,,1.33,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.33,
EZ PREP,102503,CDM,270,RC,,,,,Outpatient,,,12.6,,,,80,,10.08,percent of total billed charges,,,,85,10.71,percent of total billed charges,,,77.7,,9.79,percent of total billed charges,,,95,,11.97,percent of total billed charges,,,60,,7.56,percent of total billed charges,,7.56,11.97,
EZ PREP,102503,CDM,270,RC,,,,,Inpatient,,,12.6,,,,80,,10.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.79,percent of total billed charges,,,95,,11.97,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.97,
ANESTHESIA CIRCUIT-PED LT FREE,102504,CDM,270,RC,,,,,Outpatient,,,24.1,,,,80,,19.28,percent of total billed charges,,,,85,20.49,percent of total billed charges,,,77.7,,18.73,percent of total billed charges,,,95,,22.9,percent of total billed charges,,,60,,14.46,percent of total billed charges,,14.46,22.9,
ANESTHESIA CIRCUIT-PED LT FREE,102504,CDM,270,RC,,,,,Inpatient,,,24.1,,,,80,,19.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,18.73,percent of total billed charges,,,95,,22.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,22.9,
SUCTION CATH 18 FR.,102507,CDM,270,RC,,,,,Outpatient,,,1.3,,,,80,,1.04,percent of total billed charges,,,,85,1.11,percent of total billed charges,,,77.7,,1.01,percent of total billed charges,,,95,,1.24,percent of total billed charges,,,60,,0.78,percent of total billed charges,,0.78,1.24,
SUCTION CATH 18 FR.,102507,CDM,270,RC,,,,,Inpatient,,,1.3,,,,80,,1.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.01,percent of total billed charges,,,95,,1.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.24,
SUCTION CATHETER 10 FR W/G,102508,CDM,270,RC,,,,,Outpatient,,,2.7,,,,80,,2.16,percent of total billed charges,,,,85,2.3,percent of total billed charges,,,77.7,,2.1,percent of total billed charges,,,95,,2.57,percent of total billed charges,,,60,,1.62,percent of total billed charges,,1.62,2.57,
SUCTION CATHETER 10 FR W/G,102508,CDM,270,RC,,,,,Inpatient,,,2.7,,,,80,,2.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.1,percent of total billed charges,,,95,,2.57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.57,
STOMACH TUBE NG 22 FR,102509,CDM,270,RC,,,,,Outpatient,,,59.3,,,,80,,47.44,percent of total billed charges,,,,85,50.41,percent of total billed charges,,,77.7,,46.08,percent of total billed charges,,,95,,56.34,percent of total billed charges,,,60,,35.58,percent of total billed charges,,35.58,56.34,
STOMACH TUBE NG 22 FR,102509,CDM,270,RC,,,,,Inpatient,,,59.3,,,,80,,47.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,46.08,percent of total billed charges,,,95,,56.34,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,56.34,
MICROBORE TUBING,102512,CDM,270,RC,,,,,Outpatient,,,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
MICROBORE TUBING,102512,CDM,270,RC,,,,,Inpatient,,,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
PCA LINE,102518,CDM,270,RC,,,,,Outpatient,,,84.4,,,,80,,67.52,percent of total billed charges,,,,85,71.74,percent of total billed charges,,,77.7,,65.58,percent of total billed charges,,,95,,80.18,percent of total billed charges,,,60,,50.64,percent of total billed charges,,50.64,80.18,
PCA LINE,102518,CDM,270,RC,,,,,Inpatient,,,84.4,,,,80,,67.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,65.58,percent of total billed charges,,,95,,80.18,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,80.18,
EYE PATCH,102523,CDM,270,RC,,,,,Outpatient,,,0.3,,,,80,,0.24,percent of total billed charges,,,,85,0.26,percent of total billed charges,,,77.7,,0.23,percent of total billed charges,,,95,,0.29,percent of total billed charges,,,60,,0.18,percent of total billed charges,,0.18,0.29,
EYE PATCH,102523,CDM,270,RC,,,,,Inpatient,,,0.3,,,,80,,0.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.23,percent of total billed charges,,,95,,0.29,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,0.29,
SECONDARY PIGGYBACK,102524,CDM,270,RC,,,,,Outpatient,,,2.7,,,,80,,2.16,percent of total billed charges,,,,85,2.3,percent of total billed charges,,,77.7,,2.1,percent of total billed charges,,,95,,2.57,percent of total billed charges,,,60,,1.62,percent of total billed charges,,1.62,2.57,
SECONDARY PIGGYBACK,102524,CDM,270,RC,,,,,Inpatient,,,2.7,,,,80,,2.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.1,percent of total billed charges,,,95,,2.57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.57,
BLOOD ADMINISTRATION LINE,102528,CDM,270,RC,,,,,Outpatient,,,81.8,,,,80,,65.44,percent of total billed charges,,,,85,69.53,percent of total billed charges,,,77.7,,63.56,percent of total billed charges,,,95,,77.71,percent of total billed charges,,,60,,49.08,percent of total billed charges,,49.08,77.71,
BLOOD ADMINISTRATION LINE,102528,CDM,270,RC,,,,,Inpatient,,,81.8,,,,80,,65.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,63.56,percent of total billed charges,,,95,,77.71,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.71,
PED AEROSOL MASK,102532,CDM,270,RC,,,,,Outpatient,,,1.6,,,,80,,1.28,percent of total billed charges,,,,85,1.36,percent of total billed charges,,,77.7,,1.24,percent of total billed charges,,,95,,1.52,percent of total billed charges,,,60,,0.96,percent of total billed charges,,0.96,1.52,
PED AEROSOL MASK,102532,CDM,270,RC,,,,,Inpatient,,,1.6,,,,80,,1.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.24,percent of total billed charges,,,95,,1.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.52,
ADULT AEROSOL MASK,102533,CDM,270,RC,,,,,Outpatient,,,1.5,,,,80,,1.2,percent of total billed charges,,,,85,1.28,percent of total billed charges,,,77.7,,1.17,percent of total billed charges,,,95,,1.43,percent of total billed charges,,,60,,0.9,percent of total billed charges,,0.9,1.43,
ADULT AEROSOL MASK,102533,CDM,270,RC,,,,,Inpatient,,,1.5,,,,80,,1.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.17,percent of total billed charges,,,95,,1.43,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.43,
SUBCLAVIAN INFUSET,102535,CDM,270,RC,,,,,Outpatient,,,46.8,,,,80,,37.44,percent of total billed charges,,,,85,39.78,percent of total billed charges,,,77.7,,36.36,percent of total billed charges,,,95,,44.46,percent of total billed charges,,,60,,28.08,percent of total billed charges,,28.08,44.46,
SUBCLAVIAN INFUSET,102535,CDM,270,RC,,,,,Inpatient,,,46.8,,,,80,,37.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,36.36,percent of total billed charges,,,95,,44.46,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,44.46,
FOLEY CATH TUBE 26 FR. 5CC,102537,CDM,270,RC,,,,,Outpatient,,,6.6,,,,80,,5.28,percent of total billed charges,,,,85,5.61,percent of total billed charges,,,77.7,,5.13,percent of total billed charges,,,95,,6.27,percent of total billed charges,,,60,,3.96,percent of total billed charges,,3.96,6.27,
FOLEY CATH TUBE 26 FR. 5CC,102537,CDM,270,RC,,,,,Inpatient,,,6.6,,,,80,,5.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.13,percent of total billed charges,,,95,,6.27,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.27,
SUCTION CATH 8FR W/G,102538,CDM,270,RC,,,,,Outpatient,,,2.8,,,,80,,2.24,percent of total billed charges,,,,85,2.38,percent of total billed charges,,,77.7,,2.18,percent of total billed charges,,,95,,2.66,percent of total billed charges,,,60,,1.68,percent of total billed charges,,1.68,2.66,
SUCTION CATH 8FR W/G,102538,CDM,270,RC,,,,,Inpatient,,,2.8,,,,80,,2.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.18,percent of total billed charges,,,95,,2.66,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.66,
PRIMARY PIGGYBACK W FILTER,102539,CDM,270,RC,,,,,Outpatient,,,492.3,,,,80,,393.84,percent of total billed charges,,,,85,418.46,percent of total billed charges,,,77.7,,382.52,percent of total billed charges,,,95,,467.69,percent of total billed charges,,,60,,295.38,percent of total billed charges,,295.38,467.69,
PRIMARY PIGGYBACK W FILTER,102539,CDM,270,RC,,,,,Inpatient,,,492.3,,,,80,,393.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,382.52,percent of total billed charges,,,95,,467.69,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,467.69,
"FEEDING TUBE 8 FR 16""",102543,CDM,270,RC,,,,,Outpatient,,,3.6,,,,80,,2.88,percent of total billed charges,,,,85,3.06,percent of total billed charges,,,77.7,,2.8,percent of total billed charges,,,95,,3.42,percent of total billed charges,,,60,,2.16,percent of total billed charges,,2.16,3.42,
"FEEDING TUBE 8 FR 16""",102543,CDM,270,RC,,,,,Inpatient,,,3.6,,,,80,,2.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.8,percent of total billed charges,,,95,,3.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.42,
"ARM BOARD 3"" X 9""",102545,CDM,270,RC,,,,,Outpatient,,,1.1,,,,80,,0.88,percent of total billed charges,,,,85,0.94,percent of total billed charges,,,77.7,,0.85,percent of total billed charges,,,95,,1.05,percent of total billed charges,,,60,,0.66,percent of total billed charges,,0.66,1.05,
"ARM BOARD 3"" X 9""",102545,CDM,270,RC,,,,,Inpatient,,,1.1,,,,80,,0.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.85,percent of total billed charges,,,95,,1.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.05,
HEPARIN PRN ADAPTOR,102546,CDM,270,RC,,,,,Outpatient,,,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
HEPARIN PRN ADAPTOR,102546,CDM,270,RC,,,,,Inpatient,,,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
EXTERNAL CATHETER - SM FREEDOM,102549,CDM,270,RC,,,,,Outpatient,,,2.8,,,,80,,2.24,percent of total billed charges,,,,85,2.38,percent of total billed charges,,,77.7,,2.18,percent of total billed charges,,,95,,2.66,percent of total billed charges,,,60,,1.68,percent of total billed charges,,1.68,2.66,
EXTERNAL CATHETER - SM FREEDOM,102549,CDM,270,RC,,,,,Inpatient,,,2.8,,,,80,,2.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.18,percent of total billed charges,,,95,,2.66,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.66,
ZZZIVEX FILTER,102551,CDM,270,RC,,,,,Outpatient,,,336,,,,80,,268.8,percent of total billed charges,,,,85,285.6,percent of total billed charges,,,77.7,,261.07,percent of total billed charges,,,95,,319.2,percent of total billed charges,,,60,,201.6,percent of total billed charges,,201.6,319.2,
ZZZIVEX FILTER,102551,CDM,270,RC,,,,,Inpatient,,,336,,,,80,,268.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,261.07,percent of total billed charges,,,95,,319.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,319.2,
VENOSET BACKCHECK,102553,CDM,270,RC,,,,,Outpatient,,,11.1,,,,80,,8.88,percent of total billed charges,,,,85,9.44,percent of total billed charges,,,77.7,,8.62,percent of total billed charges,,,95,,10.55,percent of total billed charges,,,60,,6.66,percent of total billed charges,,6.66,10.55,
VENOSET BACKCHECK,102553,CDM,270,RC,,,,,Inpatient,,,11.1,,,,80,,8.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.62,percent of total billed charges,,,95,,10.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.55,
LIFESHIELD CONNECTOR,102560,CDM,270,RC,,,,,Outpatient,,,0.8,,,,80,,0.64,percent of total billed charges,,,,85,0.68,percent of total billed charges,,,77.7,,0.62,percent of total billed charges,,,95,,0.76,percent of total billed charges,,,60,,0.48,percent of total billed charges,,0.48,0.76,
LIFESHIELD CONNECTOR,102560,CDM,270,RC,,,,,Inpatient,,,0.8,,,,80,,0.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.62,percent of total billed charges,,,95,,0.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,0.76,
PREPIERCED ADAPTER,102562,CDM,270,RC,,,,,Outpatient,,,4.6,,,,80,,3.68,percent of total billed charges,,,,85,3.91,percent of total billed charges,,,77.7,,3.57,percent of total billed charges,,,95,,4.37,percent of total billed charges,,,60,,2.76,percent of total billed charges,,2.76,4.37,
PREPIERCED ADAPTER,102562,CDM,270,RC,,,,,Inpatient,,,4.6,,,,80,,3.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.57,percent of total billed charges,,,95,,4.37,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.37,
L3650 CLAVICLE SPLINT LARGE,102568,CDM,274,RC,L3650,HCPCS,,,Outpatient,,,13.7,,,,80,,10.96,percent of total billed charges,,,,85,11.65,percent of total billed charges,,,77.7,,10.64,percent of total billed charges,,,95,,13.02,percent of total billed charges,,,60,,8.22,percent of total billed charges,,8.22,13.02,
L3650 CLAVICLE SPLINT LARGE,102568,CDM,274,RC,L3650,HCPCS,,,Inpatient,,,13.7,,,,80,,10.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.64,percent of total billed charges,,,95,,13.02,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.02,
"L1830 KLINE KNEE SPLINT 12"" UNIV",102569,CDM,274,RC,L1830,HCPCS,,,Outpatient,,,36.9,,,,80,,29.52,percent of total billed charges,,,,85,31.37,percent of total billed charges,,,77.7,,28.67,percent of total billed charges,,,95,,35.06,percent of total billed charges,,,60,,22.14,percent of total billed charges,,22.14,35.06,
"L1830 KLINE KNEE SPLINT 12"" UNIV",102569,CDM,274,RC,L1830,HCPCS,,,Inpatient,,,36.9,,,,80,,29.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,28.67,percent of total billed charges,,,95,,35.06,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,35.06,
L1820 KNEE SPLINT HINGED XXL,102570,CDM,274,RC,L1820,HCPCS,,,Outpatient,,,60.6,,,,80,,48.48,percent of total billed charges,,,,50,62.07,fee schedule,,,77.7,,47.09,percent of total billed charges,,,95,,57.57,percent of total billed charges,,,60,,36.36,percent of total billed charges,,36.36,62.07,
L1820 KNEE SPLINT HINGED XXL,102570,CDM,274,RC,L1820,HCPCS,,,Inpatient,,,60.6,,,,80,,48.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,47.09,percent of total billed charges,,,95,,57.57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,57.57,
"WRIST SPLINT UNIV LT 10""",102571,CDM,270,RC,,,,,Outpatient,,,22.7,,,,80,,18.16,percent of total billed charges,,,,85,19.3,percent of total billed charges,,,77.7,,17.64,percent of total billed charges,,,95,,21.57,percent of total billed charges,,,60,,13.62,percent of total billed charges,,13.62,21.57,
"WRIST SPLINT UNIV LT 10""",102571,CDM,270,RC,,,,,Inpatient,,,22.7,,,,80,,18.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,17.64,percent of total billed charges,,,95,,21.57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,21.57,
INPERSOL PERITONEAL TRAY,102572,CDM,270,RC,,,,,Outpatient,,,3.3,,,,80,,2.64,percent of total billed charges,,,,85,2.81,percent of total billed charges,,,77.7,,2.56,percent of total billed charges,,,95,,3.14,percent of total billed charges,,,60,,1.98,percent of total billed charges,,1.98,3.14,
INPERSOL PERITONEAL TRAY,102572,CDM,270,RC,,,,,Inpatient,,,3.3,,,,80,,2.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.56,percent of total billed charges,,,95,,3.14,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.14,
ARM SLING PED BEAR PRINT,102573,CDM,270,RC,,,,,Outpatient,,,7.8,,,,80,,6.24,percent of total billed charges,,,,85,6.63,percent of total billed charges,,,77.7,,6.06,percent of total billed charges,,,95,,7.41,percent of total billed charges,,,60,,4.68,percent of total billed charges,,4.68,7.41,
ARM SLING PED BEAR PRINT,102573,CDM,270,RC,,,,,Inpatient,,,7.8,,,,80,,6.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.06,percent of total billed charges,,,95,,7.41,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.41,
L4350 AIR ANKLE LARGE RIGHT,102574,CDM,274,RC,L4350,HCPCS,,,Outpatient,,,57.6,,,,80,,46.08,percent of total billed charges,,,,85,48.96,percent of total billed charges,,,77.7,,44.76,percent of total billed charges,,,95,,54.72,percent of total billed charges,,,60,,34.56,percent of total billed charges,,34.56,54.72,
L4350 AIR ANKLE LARGE RIGHT,102574,CDM,274,RC,L4350,HCPCS,,,Inpatient,,,57.6,,,,80,,46.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,44.76,percent of total billed charges,,,95,,54.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,54.72,
VENOUS PRESSURE MONITOR,102578,CDM,270,RC,,,,,Outpatient,,,16.7,,,,80,,13.36,percent of total billed charges,,,,85,14.2,percent of total billed charges,,,77.7,,12.98,percent of total billed charges,,,95,,15.87,percent of total billed charges,,,60,,10.02,percent of total billed charges,,10.02,15.87,
VENOUS PRESSURE MONITOR,102578,CDM,270,RC,,,,,Inpatient,,,16.7,,,,80,,13.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.98,percent of total billed charges,,,95,,15.87,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.87,
MONTGOMERY STRAPS,102587,CDM,270,RC,,,,,Outpatient,,,5,,,,80,,4,percent of total billed charges,,,,85,4.25,percent of total billed charges,,,77.7,,3.89,percent of total billed charges,,,95,,4.75,percent of total billed charges,,,60,,3,percent of total billed charges,,3,4.75,
MONTGOMERY STRAPS,102587,CDM,270,RC,,,,,Inpatient,,,5,,,,80,,4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.89,percent of total billed charges,,,95,,4.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.75,
SKIN STAPLER REG.,102588,CDM,270,RC,,,,,Outpatient,,,15.9,,,,80,,12.72,percent of total billed charges,,,,85,13.52,percent of total billed charges,,,77.7,,12.35,percent of total billed charges,,,95,,15.11,percent of total billed charges,,,60,,9.54,percent of total billed charges,,9.54,15.11,
SKIN STAPLER REG.,102588,CDM,270,RC,,,,,Inpatient,,,15.9,,,,80,,12.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.35,percent of total billed charges,,,95,,15.11,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.11,
DISKARD HEAD HALTER,102592,CDM,270,RC,,,,,Outpatient,,,0.3,,,,80,,0.24,percent of total billed charges,,,,85,0.26,percent of total billed charges,,,77.7,,0.23,percent of total billed charges,,,95,,0.29,percent of total billed charges,,,60,,0.18,percent of total billed charges,,0.18,0.29,
DISKARD HEAD HALTER,102592,CDM,270,RC,,,,,Inpatient,,,0.3,,,,80,,0.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.23,percent of total billed charges,,,95,,0.29,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,0.29,
STAPLE EXTRACTOR,102593,CDM,270,RC,,,,,Outpatient,,,22.9,,,,80,,18.32,percent of total billed charges,,,,85,19.47,percent of total billed charges,,,77.7,,17.79,percent of total billed charges,,,95,,21.76,percent of total billed charges,,,60,,13.74,percent of total billed charges,,13.74,21.76,
STAPLE EXTRACTOR,102593,CDM,270,RC,,,,,Inpatient,,,22.9,,,,80,,18.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,17.79,percent of total billed charges,,,95,,21.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,21.76,
MISTY NEB WITH TEE,102596,CDM,270,RC,,,,,Outpatient,,,3.4,,,,80,,2.72,percent of total billed charges,,,,85,2.89,percent of total billed charges,,,77.7,,2.64,percent of total billed charges,,,95,,3.23,percent of total billed charges,,,60,,2.04,percent of total billed charges,,2.04,3.23,
MISTY NEB WITH TEE,102596,CDM,270,RC,,,,,Inpatient,,,3.4,,,,80,,2.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.64,percent of total billed charges,,,95,,3.23,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.23,
INTECH TUBING,102597,CDM,270,RC,,,,,Outpatient,,,2.2,,,,80,,1.76,percent of total billed charges,,,,85,1.87,percent of total billed charges,,,77.7,,1.71,percent of total billed charges,,,95,,2.09,percent of total billed charges,,,60,,1.32,percent of total billed charges,,1.32,2.09,
INTECH TUBING,102597,CDM,270,RC,,,,,Inpatient,,,2.2,,,,80,,1.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.71,percent of total billed charges,,,95,,2.09,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.09,
TRACH CARE KIT,102600,CDM,270,RC,,,,,Outpatient,,,3.4,,,,80,,2.72,percent of total billed charges,,,,85,2.89,percent of total billed charges,,,77.7,,2.64,percent of total billed charges,,,95,,3.23,percent of total billed charges,,,60,,2.04,percent of total billed charges,,2.04,3.23,
TRACH CARE KIT,102600,CDM,270,RC,,,,,Inpatient,,,3.4,,,,80,,2.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.64,percent of total billed charges,,,95,,3.23,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.23,
EGG CRATE COVER,102601,CDM,270,RC,,,,,Outpatient,,,8.3,,,,80,,6.64,percent of total billed charges,,,,85,7.06,percent of total billed charges,,,77.7,,6.45,percent of total billed charges,,,95,,7.89,percent of total billed charges,,,60,,4.98,percent of total billed charges,,4.98,7.89,
EGG CRATE COVER,102601,CDM,270,RC,,,,,Inpatient,,,8.3,,,,80,,6.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.45,percent of total billed charges,,,95,,7.89,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.89,
TRACH MASK,102602,CDM,270,RC,,,,,Outpatient,,,2.7,,,,80,,2.16,percent of total billed charges,,,,85,2.3,percent of total billed charges,,,77.7,,2.1,percent of total billed charges,,,95,,2.57,percent of total billed charges,,,60,,1.62,percent of total billed charges,,1.62,2.57,
TRACH MASK,102602,CDM,270,RC,,,,,Inpatient,,,2.7,,,,80,,2.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.1,percent of total billed charges,,,95,,2.57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.57,
CATHETER LEG STRAP,102603,CDM,270,RC,,,,,Outpatient,,,5.5,,,,80,,4.4,percent of total billed charges,,,,85,4.68,percent of total billed charges,,,77.7,,4.27,percent of total billed charges,,,95,,5.23,percent of total billed charges,,,60,,3.3,percent of total billed charges,,3.3,5.23,
CATHETER LEG STRAP,102603,CDM,270,RC,,,,,Inpatient,,,5.5,,,,80,,4.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.27,percent of total billed charges,,,95,,5.23,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.23,
CANNULA O2 25 FT,102604,CDM,270,RC,,,,,Outpatient,,,5.9,,,,80,,4.72,percent of total billed charges,,,,85,5.02,percent of total billed charges,,,77.7,,4.58,percent of total billed charges,,,95,,5.61,percent of total billed charges,,,60,,3.54,percent of total billed charges,,3.54,5.61,
CANNULA O2 25 FT,102604,CDM,270,RC,,,,,Inpatient,,,5.9,,,,80,,4.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.58,percent of total billed charges,,,95,,5.61,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.61,
CLIPPER BLADES,102606,CDM,270,RC,,,,,Outpatient,,,7.1,,,,80,,5.68,percent of total billed charges,,,,85,6.04,percent of total billed charges,,,77.7,,5.52,percent of total billed charges,,,95,,6.75,percent of total billed charges,,,60,,4.26,percent of total billed charges,,4.26,6.75,
CLIPPER BLADES,102606,CDM,270,RC,,,,,Inpatient,,,7.1,,,,80,,5.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.52,percent of total billed charges,,,95,,6.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.75,
CONNECTOR 6 IN 1,102607,CDM,270,RC,,,,,Outpatient,,,3,,,,80,,2.4,percent of total billed charges,,,,85,2.55,percent of total billed charges,,,77.7,,2.33,percent of total billed charges,,,95,,2.85,percent of total billed charges,,,60,,1.8,percent of total billed charges,,1.8,2.85,
CONNECTOR 6 IN 1,102607,CDM,270,RC,,,,,Inpatient,,,3,,,,80,,2.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.33,percent of total billed charges,,,95,,2.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.85,
DEFIB-PADS,102609,CDM,270,RC,,,,,Outpatient,,,15.6,,,,80,,12.48,percent of total billed charges,,,,85,13.26,percent of total billed charges,,,77.7,,12.12,percent of total billed charges,,,95,,14.82,percent of total billed charges,,,60,,9.36,percent of total billed charges,,9.36,14.82,
DEFIB-PADS,102609,CDM,270,RC,,,,,Inpatient,,,15.6,,,,80,,12.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.12,percent of total billed charges,,,95,,14.82,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,14.82,
ELASTO-GEL,102613,CDM,270,RC,,,,,Outpatient,,,25.3,,,,80,,20.24,percent of total billed charges,,,,85,21.51,percent of total billed charges,,,77.7,,19.66,percent of total billed charges,,,95,,24.04,percent of total billed charges,,,60,,15.18,percent of total billed charges,,15.18,24.04,
ELASTO-GEL,102613,CDM,270,RC,,,,,Inpatient,,,25.3,,,,80,,20.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.66,percent of total billed charges,,,95,,24.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,24.04,
CPM SOFTGOODS,102614,CDM,270,RC,,,,,Outpatient,,,6.1,,,,80,,4.88,percent of total billed charges,,,,85,5.19,percent of total billed charges,,,77.7,,4.74,percent of total billed charges,,,95,,5.8,percent of total billed charges,,,60,,3.66,percent of total billed charges,,3.66,5.8,
CPM SOFTGOODS,102614,CDM,270,RC,,,,,Inpatient,,,6.1,,,,80,,4.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.74,percent of total billed charges,,,95,,5.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.8,
FOLEY CATH 16FR 30CC 3WAY,102615,CDM,270,RC,,,,,Outpatient,,,20.1,,,,80,,16.08,percent of total billed charges,,,,85,17.09,percent of total billed charges,,,77.7,,15.62,percent of total billed charges,,,95,,19.1,percent of total billed charges,,,60,,12.06,percent of total billed charges,,12.06,19.1,
FOLEY CATH 16FR 30CC 3WAY,102615,CDM,270,RC,,,,,Inpatient,,,20.1,,,,80,,16.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,15.62,percent of total billed charges,,,95,,19.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,19.1,
COUDE CATHETER - 16 FR.,102616,CDM,270,RC,,,,,Outpatient,,,29.8,,,,80,,23.84,percent of total billed charges,,,,85,25.33,percent of total billed charges,,,77.7,,23.15,percent of total billed charges,,,95,,28.31,percent of total billed charges,,,60,,17.88,percent of total billed charges,,17.88,28.31,
COUDE CATHETER - 16 FR.,102616,CDM,270,RC,,,,,Inpatient,,,29.8,,,,80,,23.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,23.15,percent of total billed charges,,,95,,28.31,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,28.31,
VAGINAL TRAY,102617,CDM,270,RC,,,,,Outpatient,,,0.1,,,,80,,0.08,percent of total billed charges,,,,85,0.09,percent of total billed charges,,,77.7,,0.08,percent of total billed charges,,,95,,0.1,percent of total billed charges,,,60,,0.06,percent of total billed charges,,0.06,0.1,
VAGINAL TRAY,102617,CDM,270,RC,,,,,Inpatient,,,0.1,,,,80,,0.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.08,percent of total billed charges,,,95,,0.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,0.1,
RECTAL SURGICAL TRAY,102618,CDM,270,RC,,,,,Outpatient,,,0.1,,,,80,,0.08,percent of total billed charges,,,,85,0.09,percent of total billed charges,,,77.7,,0.08,percent of total billed charges,,,95,,0.1,percent of total billed charges,,,60,,0.06,percent of total billed charges,,0.06,0.1,
RECTAL SURGICAL TRAY,102618,CDM,270,RC,,,,,Inpatient,,,0.1,,,,80,,0.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.08,percent of total billed charges,,,95,,0.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,0.1,
SCD SLEEVE KNEE HIGH REGULAR,102620,CDM,270,RC,,,,,Outpatient,,,38.5,,,,80,,30.8,percent of total billed charges,,,,85,32.73,percent of total billed charges,,,77.7,,29.91,percent of total billed charges,,,95,,36.58,percent of total billed charges,,,60,,23.1,percent of total billed charges,,23.1,36.58,
SCD SLEEVE KNEE HIGH REGULAR,102620,CDM,270,RC,,,,,Inpatient,,,38.5,,,,80,,30.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,29.91,percent of total billed charges,,,95,,36.58,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,36.58,
SURGIWAND W/L HOOK DISECTOR,102622,CDM,270,RC,,,,,Outpatient,,,598.4,,,,80,,478.72,percent of total billed charges,,,,85,508.64,percent of total billed charges,,,77.7,,464.96,percent of total billed charges,,,95,,568.48,percent of total billed charges,,,60,,359.04,percent of total billed charges,,359.04,568.48,
SURGIWAND W/L HOOK DISECTOR,102622,CDM,270,RC,,,,,Inpatient,,,598.4,,,,80,,478.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,464.96,percent of total billed charges,,,95,,568.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,568.48,
COMBO DEFIB PATCHES PED,102623,CDM,270,RC,,,,,Outpatient,,,87.5,,,,80,,70,percent of total billed charges,,,,85,74.38,percent of total billed charges,,,77.7,,67.99,percent of total billed charges,,,95,,83.13,percent of total billed charges,,,60,,52.5,percent of total billed charges,,52.5,83.13,
COMBO DEFIB PATCHES PED,102623,CDM,270,RC,,,,,Inpatient,,,87.5,,,,80,,70,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,67.99,percent of total billed charges,,,95,,83.13,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,83.13,
UTERINE CURETTE 8MM,102624,CDM,270,RC,,,,,Outpatient,,,4.2,,,,80,,3.36,percent of total billed charges,,,,85,3.57,percent of total billed charges,,,77.7,,3.26,percent of total billed charges,,,95,,3.99,percent of total billed charges,,,60,,2.52,percent of total billed charges,,2.52,3.99,
UTERINE CURETTE 8MM,102624,CDM,270,RC,,,,,Inpatient,,,4.2,,,,80,,3.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.26,percent of total billed charges,,,95,,3.99,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.99,
THORACIC CATHETER 20 FR,102625,CDM,270,RC,,,,,Outpatient,,,16.3,,,,80,,13.04,percent of total billed charges,,,,85,13.86,percent of total billed charges,,,77.7,,12.67,percent of total billed charges,,,95,,15.49,percent of total billed charges,,,60,,9.78,percent of total billed charges,,9.78,15.49,
THORACIC CATHETER 20 FR,102625,CDM,270,RC,,,,,Inpatient,,,16.3,,,,80,,13.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.67,percent of total billed charges,,,95,,15.49,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.49,
INTUBATING 10 FR STYLETTE,102628,CDM,270,RC,,,,,Outpatient,,,5.2,,,,80,,4.16,percent of total billed charges,,,,85,4.42,percent of total billed charges,,,77.7,,4.04,percent of total billed charges,,,95,,4.94,percent of total billed charges,,,60,,3.12,percent of total billed charges,,3.12,4.94,
INTUBATING 10 FR STYLETTE,102628,CDM,270,RC,,,,,Inpatient,,,5.2,,,,80,,4.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.04,percent of total billed charges,,,95,,4.94,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.94,
LUMBAR PUNCTURE TRAY CHILD/INFANT,102630,CDM,270,RC,,,,,Outpatient,,,24.2,,,,80,,19.36,percent of total billed charges,,,,85,20.57,percent of total billed charges,,,77.7,,18.8,percent of total billed charges,,,95,,22.99,percent of total billed charges,,,60,,14.52,percent of total billed charges,,14.52,22.99,
LUMBAR PUNCTURE TRAY CHILD/INFANT,102630,CDM,270,RC,,,,,Inpatient,,,24.2,,,,80,,19.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,18.8,percent of total billed charges,,,95,,22.99,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,22.99,
ENDOTRACH TUBE 8.0 RAE,102632,CDM,270,RC,,,,,Outpatient,,,14.5,,,,80,,11.6,percent of total billed charges,,,,85,12.33,percent of total billed charges,,,77.7,,11.27,percent of total billed charges,,,95,,13.78,percent of total billed charges,,,60,,8.7,percent of total billed charges,,8.7,13.78,
ENDOTRACH TUBE 8.0 RAE,102632,CDM,270,RC,,,,,Inpatient,,,14.5,,,,80,,11.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.27,percent of total billed charges,,,95,,13.78,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.78,
ENDOTRACH TUBE 3.5 UNCUFFED,102633,CDM,270,RC,,,,,Outpatient,,,2.9,,,,80,,2.32,percent of total billed charges,,,,85,2.47,percent of total billed charges,,,77.7,,2.25,percent of total billed charges,,,95,,2.76,percent of total billed charges,,,60,,1.74,percent of total billed charges,,1.74,2.76,
ENDOTRACH TUBE 3.5 UNCUFFED,102633,CDM,270,RC,,,,,Inpatient,,,2.9,,,,80,,2.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.25,percent of total billed charges,,,95,,2.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.76,
ENDOTRACH TUBE 4.0 CUFFED,102635,CDM,270,RC,,,,,Outpatient,,,4.7,,,,80,,3.76,percent of total billed charges,,,,85,4,percent of total billed charges,,,77.7,,3.65,percent of total billed charges,,,95,,4.47,percent of total billed charges,,,60,,2.82,percent of total billed charges,,2.82,4.47,
ENDOTRACH TUBE 4.0 CUFFED,102635,CDM,270,RC,,,,,Inpatient,,,4.7,,,,80,,3.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.65,percent of total billed charges,,,95,,4.47,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.47,
EMERGENCY TRACH KIT,102638,CDM,270,RC,,,,,Outpatient,,,16.3,,,,80,,13.04,percent of total billed charges,,,,85,13.86,percent of total billed charges,,,77.7,,12.67,percent of total billed charges,,,95,,15.49,percent of total billed charges,,,60,,9.78,percent of total billed charges,,9.78,15.49,
EMERGENCY TRACH KIT,102638,CDM,270,RC,,,,,Inpatient,,,16.3,,,,80,,13.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.67,percent of total billed charges,,,95,,15.49,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.49,
INTRAOSSEOUS NEEDLE 15G,102640,CDM,270,RC,,,,,Outpatient,,,34.9,,,,80,,27.92,percent of total billed charges,,,,85,29.67,percent of total billed charges,,,77.7,,27.12,percent of total billed charges,,,95,,33.16,percent of total billed charges,,,60,,20.94,percent of total billed charges,,20.94,33.16,
INTRAOSSEOUS NEEDLE 15G,102640,CDM,270,RC,,,,,Inpatient,,,34.9,,,,80,,27.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,27.12,percent of total billed charges,,,95,,33.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,33.16,
NEEDLE SPINAL WHITACRE 25 X 3 1/2,102641,CDM,270,RC,,,,,Outpatient,,,35.9,,,,80,,28.72,percent of total billed charges,,,,85,30.52,percent of total billed charges,,,77.7,,27.89,percent of total billed charges,,,95,,34.11,percent of total billed charges,,,60,,21.54,percent of total billed charges,,21.54,34.11,
NEEDLE SPINAL WHITACRE 25 X 3 1/2,102641,CDM,270,RC,,,,,Inpatient,,,35.9,,,,80,,28.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,27.89,percent of total billed charges,,,95,,34.11,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,34.11,
NEEDLE SPINAL 25 X 4 11/16 WHITCARE,102642,CDM,270,RC,,,,,Outpatient,,,22.6,,,,80,,18.08,percent of total billed charges,,,,85,19.21,percent of total billed charges,,,77.7,,17.56,percent of total billed charges,,,95,,21.47,percent of total billed charges,,,60,,13.56,percent of total billed charges,,13.56,21.47,
NEEDLE SPINAL 25 X 4 11/16 WHITCARE,102642,CDM,270,RC,,,,,Inpatient,,,22.6,,,,80,,18.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,17.56,percent of total billed charges,,,95,,21.47,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,21.47,
NEEDLE SPINAL QUINKE 22 X 3 1/2,102643,CDM,270,RC,,,,,Outpatient,,,9.6,,,,80,,7.68,percent of total billed charges,,,,85,8.16,percent of total billed charges,,,77.7,,7.46,percent of total billed charges,,,95,,9.12,percent of total billed charges,,,60,,5.76,percent of total billed charges,,5.76,9.12,
NEEDLE SPINAL QUINKE 22 X 3 1/2,102643,CDM,270,RC,,,,,Inpatient,,,9.6,,,,80,,7.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.46,percent of total billed charges,,,95,,9.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.12,
NEEDLE SPINAL QUINKE 22 X 1 1/2,102644,CDM,270,RC,,,,,Outpatient,,,8.8,,,,80,,7.04,percent of total billed charges,,,,85,7.48,percent of total billed charges,,,77.7,,6.84,percent of total billed charges,,,95,,8.36,percent of total billed charges,,,60,,5.28,percent of total billed charges,,5.28,8.36,
NEEDLE SPINAL QUINKE 22 X 1 1/2,102644,CDM,270,RC,,,,,Inpatient,,,8.8,,,,80,,7.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.84,percent of total billed charges,,,95,,8.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,8.36,
"ACE BANDAGE 2""",102653,CDM,270,RC,,,,,Outpatient,,,1.3,,,,80,,1.04,percent of total billed charges,,,,85,1.11,percent of total billed charges,,,77.7,,1.01,percent of total billed charges,,,95,,1.24,percent of total billed charges,,,60,,0.78,percent of total billed charges,,0.78,1.24,
"ACE BANDAGE 2""",102653,CDM,270,RC,,,,,Inpatient,,,1.3,,,,80,,1.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.01,percent of total billed charges,,,95,,1.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.24,
"ACE BANDAGE 3""",102654,CDM,270,RC,,,,,Outpatient,,,2.7,,,,80,,2.16,percent of total billed charges,,,,85,2.3,percent of total billed charges,,,77.7,,2.1,percent of total billed charges,,,95,,2.57,percent of total billed charges,,,60,,1.62,percent of total billed charges,,1.62,2.57,
"ACE BANDAGE 3""",102654,CDM,270,RC,,,,,Inpatient,,,2.7,,,,80,,2.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.1,percent of total billed charges,,,95,,2.57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.57,
"ACE BANDAGE 6""",102655,CDM,270,RC,,,,,Outpatient,,,6.2,,,,80,,4.96,percent of total billed charges,,,,85,5.27,percent of total billed charges,,,77.7,,4.82,percent of total billed charges,,,95,,5.89,percent of total billed charges,,,60,,3.72,percent of total billed charges,,3.72,5.89,
"ACE BANDAGE 6""",102655,CDM,270,RC,,,,,Inpatient,,,6.2,,,,80,,4.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.82,percent of total billed charges,,,95,,5.89,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.89,
CANNULA PEDIACTRIC,102656,CDM,270,RC,,,,,Outpatient,,,4.5,,,,80,,3.6,percent of total billed charges,,,,85,3.83,percent of total billed charges,,,77.7,,3.5,percent of total billed charges,,,95,,4.28,percent of total billed charges,,,60,,2.7,percent of total billed charges,,2.7,4.28,
CANNULA PEDIACTRIC,102656,CDM,270,RC,,,,,Inpatient,,,4.5,,,,80,,3.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.5,percent of total billed charges,,,95,,4.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.28,
AIRWAY ORAL #12,102659,CDM,270,RC,,,,,Outpatient,,,1.2,,,,80,,0.96,percent of total billed charges,,,,85,1.02,percent of total billed charges,,,77.7,,0.93,percent of total billed charges,,,95,,1.14,percent of total billed charges,,,60,,0.72,percent of total billed charges,,0.72,1.14,
AIRWAY ORAL #12,102659,CDM,270,RC,,,,,Inpatient,,,1.2,,,,80,,0.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.93,percent of total billed charges,,,95,,1.14,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.14,
O2 MASK ELONGATED,102664,CDM,270,RC,,,,,Outpatient,,,2.2,,,,80,,1.76,percent of total billed charges,,,,85,1.87,percent of total billed charges,,,77.7,,1.71,percent of total billed charges,,,95,,2.09,percent of total billed charges,,,60,,1.32,percent of total billed charges,,1.32,2.09,
O2 MASK ELONGATED,102664,CDM,270,RC,,,,,Inpatient,,,2.2,,,,80,,1.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.71,percent of total billed charges,,,95,,2.09,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.09,
FOLEY CATH KIT 18FR LATEX FREE,102665,CDM,270,RC,,,,,Outpatient,,,8.1,,,,80,,6.48,percent of total billed charges,,,,85,6.89,percent of total billed charges,,,77.7,,6.29,percent of total billed charges,,,95,,7.7,percent of total billed charges,,,60,,4.86,percent of total billed charges,,4.86,7.7,
FOLEY CATH KIT 18FR LATEX FREE,102665,CDM,270,RC,,,,,Inpatient,,,8.1,,,,80,,6.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.29,percent of total billed charges,,,95,,7.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.7,
C2617 URETHRAL CATH KIT 16 FR PLASTIC,102666,CDM,270,RC,,,,,Outpatient,,,7.7,,,,80,,6.16,percent of total billed charges,,,,85,6.55,percent of total billed charges,,,77.7,,5.98,percent of total billed charges,,,95,,7.32,percent of total billed charges,,,60,,4.62,percent of total billed charges,,4.62,7.32,
C2617 URETHRAL CATH KIT 16 FR PLASTIC,102666,CDM,270,RC,,,,,Inpatient,,,7.7,,,,80,,6.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.98,percent of total billed charges,,,95,,7.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.32,
CATHETER LEG BAG,102667,CDM,270,RC,,,,,Outpatient,,,2.1,,,,80,,1.68,percent of total billed charges,,,,85,1.79,percent of total billed charges,,,77.7,,1.63,percent of total billed charges,,,95,,2,percent of total billed charges,,,60,,1.26,percent of total billed charges,,1.26,2,
CATHETER LEG BAG,102667,CDM,270,RC,,,,,Inpatient,,,2.1,,,,80,,1.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.63,percent of total billed charges,,,95,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2,
L0120 CERVICAL COLLAR SM,102669,CDM,274,RC,L0120,HCPCS,,,Outpatient,,,11.5,,,,80,,9.2,percent of total billed charges,,,,85,9.78,percent of total billed charges,,,77.7,,8.94,percent of total billed charges,,,95,,10.93,percent of total billed charges,,,60,,6.9,percent of total billed charges,,6.9,10.93,
L0120 CERVICAL COLLAR SM,102669,CDM,274,RC,L0120,HCPCS,,,Inpatient,,,11.5,,,,80,,9.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.94,percent of total billed charges,,,95,,10.93,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.93,
CAST BOOT MED,102670,CDM,270,RC,,,,,Outpatient,,,20.5,,,,80,,16.4,percent of total billed charges,,,,85,17.43,percent of total billed charges,,,77.7,,15.93,percent of total billed charges,,,95,,19.48,percent of total billed charges,,,60,,12.3,percent of total billed charges,,12.3,19.48,
CAST BOOT MED,102670,CDM,270,RC,,,,,Inpatient,,,20.5,,,,80,,16.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,15.93,percent of total billed charges,,,95,,19.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,19.48,
L3260 HEALING SHOE MEDIUM,102671,CDM,274,RC,L3260,HCPCS,,,Outpatient,,,18.3,,,,80,,14.64,percent of total billed charges,,,,85,15.56,percent of total billed charges,,,77.7,,14.22,percent of total billed charges,,,95,,17.39,percent of total billed charges,,,60,,10.98,percent of total billed charges,,10.98,17.39,
L3260 HEALING SHOE MEDIUM,102671,CDM,274,RC,L3260,HCPCS,,,Inpatient,,,18.3,,,,80,,14.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.22,percent of total billed charges,,,95,,17.39,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.39,
"RIB BELT MEN 6"" UNIVERSAL",102672,CDM,270,RC,,,,,Outpatient,,,10.8,,,,80,,8.64,percent of total billed charges,,,,85,9.18,percent of total billed charges,,,77.7,,8.39,percent of total billed charges,,,95,,10.26,percent of total billed charges,,,60,,6.48,percent of total billed charges,,6.48,10.26,
"RIB BELT MEN 6"" UNIVERSAL",102672,CDM,270,RC,,,,,Inpatient,,,10.8,,,,80,,8.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.39,percent of total billed charges,,,95,,10.26,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.26,
NASAL PACKING-LARGE,102673,CDM,270,RC,,,,,Outpatient,,,33.2,,,,80,,26.56,percent of total billed charges,,,,85,28.22,percent of total billed charges,,,77.7,,25.8,percent of total billed charges,,,95,,31.54,percent of total billed charges,,,60,,19.92,percent of total billed charges,,19.92,31.54,
NASAL PACKING-LARGE,102673,CDM,270,RC,,,,,Inpatient,,,33.2,,,,80,,26.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,25.8,percent of total billed charges,,,95,,31.54,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,31.54,
NASAL PACKING - SM,102674,CDM,270,RC,,,,,Outpatient,,,32.6,,,,80,,26.08,percent of total billed charges,,,,85,27.71,percent of total billed charges,,,77.7,,25.33,percent of total billed charges,,,95,,30.97,percent of total billed charges,,,60,,19.56,percent of total billed charges,,19.56,30.97,
NASAL PACKING - SM,102674,CDM,270,RC,,,,,Inpatient,,,32.6,,,,80,,26.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,25.33,percent of total billed charges,,,95,,30.97,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,30.97,
"RIB BELT WOMEN 6"" UNIVERSAL",102675,CDM,270,RC,,,,,Outpatient,,,12.5,,,,80,,10,percent of total billed charges,,,,85,10.63,percent of total billed charges,,,77.7,,9.71,percent of total billed charges,,,95,,11.88,percent of total billed charges,,,60,,7.5,percent of total billed charges,,7.5,11.88,
"RIB BELT WOMEN 6"" UNIVERSAL",102675,CDM,270,RC,,,,,Inpatient,,,12.5,,,,80,,10,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.71,percent of total billed charges,,,95,,11.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.88,
SUTURE BONE WAX  OR,102676,CDM,270,RC,,,,,Outpatient,,,24.3,,,,80,,19.44,percent of total billed charges,,,,85,20.66,percent of total billed charges,,,77.7,,18.88,percent of total billed charges,,,95,,23.09,percent of total billed charges,,,60,,14.58,percent of total billed charges,,14.58,23.09,
SUTURE BONE WAX  OR,102676,CDM,270,RC,,,,,Inpatient,,,24.3,,,,80,,19.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,18.88,percent of total billed charges,,,95,,23.09,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,23.09,
NASAL CATHETER SILICONE,102679,CDM,270,RC,,,,,Outpatient,,,168.1,,,,80,,134.48,percent of total billed charges,,,,85,142.89,percent of total billed charges,,,77.7,,130.61,percent of total billed charges,,,95,,159.7,percent of total billed charges,,,60,,100.86,percent of total billed charges,,100.86,159.7,
NASAL CATHETER SILICONE,102679,CDM,270,RC,,,,,Inpatient,,,168.1,,,,80,,134.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,130.61,percent of total billed charges,,,95,,159.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,159.7,
EASI-LAVAGE,102680,CDM,270,RC,,,,,Outpatient,,,186.4,,,,80,,149.12,percent of total billed charges,,,,85,158.44,percent of total billed charges,,,77.7,,144.83,percent of total billed charges,,,95,,177.08,percent of total billed charges,,,60,,111.84,percent of total billed charges,,111.84,177.08,
EASI-LAVAGE,102680,CDM,270,RC,,,,,Inpatient,,,186.4,,,,80,,149.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,144.83,percent of total billed charges,,,95,,177.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,177.08,
ABOCATH,102681,CDM,270,RC,,,,,Outpatient,,,3.1,,,,80,,2.48,percent of total billed charges,,,,85,2.64,percent of total billed charges,,,77.7,,2.41,percent of total billed charges,,,95,,2.95,percent of total billed charges,,,60,,1.86,percent of total billed charges,,1.86,2.95,
ABOCATH,102681,CDM,270,RC,,,,,Inpatient,,,3.1,,,,80,,2.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.41,percent of total billed charges,,,95,,2.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.95,
BLOOD SOLUTION LINE GRAVITY,102684,CDM,270,RC,,,,,Outpatient,,,17.2,,,,80,,13.76,percent of total billed charges,,,,85,14.62,percent of total billed charges,,,77.7,,13.36,percent of total billed charges,,,95,,16.34,percent of total billed charges,,,60,,10.32,percent of total billed charges,,10.32,16.34,
BLOOD SOLUTION LINE GRAVITY,102684,CDM,270,RC,,,,,Inpatient,,,17.2,,,,80,,13.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,13.36,percent of total billed charges,,,95,,16.34,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,16.34,
PRESSPATCH EYESHIELD,102686,CDM,270,RC,,,,,Outpatient,,,52.2,,,,80,,41.76,percent of total billed charges,,,,85,44.37,percent of total billed charges,,,77.7,,40.56,percent of total billed charges,,,95,,49.59,percent of total billed charges,,,60,,31.32,percent of total billed charges,,31.32,49.59,
PRESSPATCH EYESHIELD,102686,CDM,270,RC,,,,,Inpatient,,,52.2,,,,80,,41.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,40.56,percent of total billed charges,,,95,,49.59,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,49.59,
MULTI-LUMEN CATHETER,102687,CDM,270,RC,,,,,Outpatient,,,173.1,,,,80,,138.48,percent of total billed charges,,,,85,147.14,percent of total billed charges,,,77.7,,134.5,percent of total billed charges,,,95,,164.45,percent of total billed charges,,,60,,103.86,percent of total billed charges,,103.86,164.45,
MULTI-LUMEN CATHETER,102687,CDM,270,RC,,,,,Inpatient,,,173.1,,,,80,,138.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,134.5,percent of total billed charges,,,95,,164.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,164.45,
FOLEY CATHETER 22F 5CC,102688,CDM,270,RC,,,,,Outpatient,,,6.4,,,,80,,5.12,percent of total billed charges,,,,85,5.44,percent of total billed charges,,,77.7,,4.97,percent of total billed charges,,,95,,6.08,percent of total billed charges,,,60,,3.84,percent of total billed charges,,3.84,6.08,
FOLEY CATHETER 22F 5CC,102688,CDM,270,RC,,,,,Inpatient,,,6.4,,,,80,,5.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.97,percent of total billed charges,,,95,,6.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.08,
"ARM BOARD ADULT 3"" x 17 1/2""",102690,CDM,270,RC,,,,,Outpatient,,,2.7,,,,80,,2.16,percent of total billed charges,,,,85,2.3,percent of total billed charges,,,77.7,,2.1,percent of total billed charges,,,95,,2.57,percent of total billed charges,,,60,,1.62,percent of total billed charges,,1.62,2.57,
"ARM BOARD ADULT 3"" x 17 1/2""",102690,CDM,270,RC,,,,,Inpatient,,,2.7,,,,80,,2.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.1,percent of total billed charges,,,95,,2.57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.57,
EXTERNAL CATHETER MED BARD,102692,CDM,270,RC,,,,,Outpatient,,,6.1,,,,80,,4.88,percent of total billed charges,,,,85,5.19,percent of total billed charges,,,77.7,,4.74,percent of total billed charges,,,95,,5.8,percent of total billed charges,,,60,,3.66,percent of total billed charges,,3.66,5.8,
EXTERNAL CATHETER MED BARD,102692,CDM,270,RC,,,,,Inpatient,,,6.1,,,,80,,4.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.74,percent of total billed charges,,,95,,5.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.8,
CHEST DRAINAGE UNIT,102696,CDM,270,RC,,,,,Outpatient,,,325.3,,,,80,,260.24,percent of total billed charges,,,,85,276.51,percent of total billed charges,,,77.7,,252.76,percent of total billed charges,,,95,,309.04,percent of total billed charges,,,60,,195.18,percent of total billed charges,,195.18,309.04,
CHEST DRAINAGE UNIT,102696,CDM,270,RC,,,,,Inpatient,,,325.3,,,,80,,260.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,252.76,percent of total billed charges,,,95,,309.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,309.04,
UNDERWATER DRAINAGE SYSTEM,102697,CDM,270,RC,,,,,Outpatient,,,11.1,,,,80,,8.88,percent of total billed charges,,,,85,9.44,percent of total billed charges,,,77.7,,8.62,percent of total billed charges,,,95,,10.55,percent of total billed charges,,,60,,6.66,percent of total billed charges,,6.66,10.55,
UNDERWATER DRAINAGE SYSTEM,102697,CDM,270,RC,,,,,Inpatient,,,11.1,,,,80,,8.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.62,percent of total billed charges,,,95,,10.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.55,
"WRIST SPLINT UNIV RT 7""",102698,CDM,270,RC,,,,,Outpatient,,,16,,,,80,,12.8,percent of total billed charges,,,,85,13.6,percent of total billed charges,,,77.7,,12.43,percent of total billed charges,,,95,,15.2,percent of total billed charges,,,60,,9.6,percent of total billed charges,,9.6,15.2,
"WRIST SPLINT UNIV RT 7""",102698,CDM,270,RC,,,,,Inpatient,,,16,,,,80,,12.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.43,percent of total billed charges,,,95,,15.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.2,
CLAVICLE SPLINT SMALL,102699,CDM,270,RC,,,,,Outpatient,,,13.7,,,,80,,10.96,percent of total billed charges,,,,85,11.65,percent of total billed charges,,,77.7,,10.64,percent of total billed charges,,,95,,13.02,percent of total billed charges,,,60,,8.22,percent of total billed charges,,8.22,13.02,
CLAVICLE SPLINT SMALL,102699,CDM,270,RC,,,,,Inpatient,,,13.7,,,,80,,10.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.64,percent of total billed charges,,,95,,13.02,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.02,
L0628 LUMBO SACRAL SUPPORT UNIV DEROYAL,102700,CDM,274,RC,L0628,HCPCS,,,Outpatient,,,75,,,,80,,60,percent of total billed charges,,,,50,38.57,fee schedule,,,77.7,,58.28,percent of total billed charges,,,95,,71.25,percent of total billed charges,,,60,,45,percent of total billed charges,,38.57,71.25,
L0628 LUMBO SACRAL SUPPORT UNIV DEROYAL,102700,CDM,274,RC,L0628,HCPCS,,,Inpatient,,,75,,,,80,,60,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,58.28,percent of total billed charges,,,95,,71.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,71.25,
"L0628 LUMBO SACRAL SUPPORT 13""",102701,CDM,274,RC,L0628,HCPCS,,,Outpatient,,,13.8,,,,80,,11.04,percent of total billed charges,,,,50,38.57,fee schedule,,,77.7,,10.72,percent of total billed charges,,,95,,13.11,percent of total billed charges,,,60,,8.28,percent of total billed charges,,8.28,38.57,
"L0628 LUMBO SACRAL SUPPORT 13""",102701,CDM,274,RC,L0628,HCPCS,,,Inpatient,,,13.8,,,,80,,11.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.72,percent of total billed charges,,,95,,13.11,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.11,
BUCKS TRACTION SET,102702,CDM,270,RC,,,,,Outpatient,,,7.6,,,,80,,6.08,percent of total billed charges,,,,85,6.46,percent of total billed charges,,,77.7,,5.91,percent of total billed charges,,,95,,7.22,percent of total billed charges,,,60,,4.56,percent of total billed charges,,4.56,7.22,
BUCKS TRACTION SET,102702,CDM,270,RC,,,,,Inpatient,,,7.6,,,,80,,6.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.91,percent of total billed charges,,,95,,7.22,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.22,
"L1830 KLINE KNEE SPLINT 14"" UNIV",102703,CDM,274,RC,L1830,HCPCS,,,Outpatient,,,43.6,,,,80,,34.88,percent of total billed charges,,,,85,37.06,percent of total billed charges,,,77.7,,33.88,percent of total billed charges,,,95,,41.42,percent of total billed charges,,,60,,26.16,percent of total billed charges,,26.16,41.42,
"L1830 KLINE KNEE SPLINT 14"" UNIV",102703,CDM,274,RC,L1830,HCPCS,,,Inpatient,,,43.6,,,,80,,34.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,33.88,percent of total billed charges,,,95,,41.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,41.42,
"L1830 KLINE KNEE SPLINT 16"" UNIV",102704,CDM,274,RC,L1830,HCPCS,,,Outpatient,,,43.3,,,,80,,34.64,percent of total billed charges,,,,85,36.81,percent of total billed charges,,,77.7,,33.64,percent of total billed charges,,,95,,41.14,percent of total billed charges,,,60,,25.98,percent of total billed charges,,25.98,41.14,
"L1830 KLINE KNEE SPLINT 16"" UNIV",102704,CDM,274,RC,L1830,HCPCS,,,Inpatient,,,43.3,,,,80,,34.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,33.64,percent of total billed charges,,,95,,41.14,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,41.14,
"L1830 KLINE KNEE SPLINT 20"" UNIV",102705,CDM,274,RC,L1830,HCPCS,,,Outpatient,,,44.7,,,,80,,35.76,percent of total billed charges,,,,85,38,percent of total billed charges,,,77.7,,34.73,percent of total billed charges,,,95,,42.47,percent of total billed charges,,,60,,26.82,percent of total billed charges,,26.82,42.47,
"L1830 KLINE KNEE SPLINT 20"" UNIV",102705,CDM,274,RC,L1830,HCPCS,,,Inpatient,,,44.7,,,,80,,35.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,34.73,percent of total billed charges,,,95,,42.47,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,42.47,
"L1830 KLINE KNEE SPLINT 22""",102706,CDM,274,RC,L1830,HCPCS,,,Outpatient,,,54.4,,,,80,,43.52,percent of total billed charges,,,,85,46.24,percent of total billed charges,,,77.7,,42.27,percent of total billed charges,,,95,,51.68,percent of total billed charges,,,60,,32.64,percent of total billed charges,,32.64,51.68,
"L1830 KLINE KNEE SPLINT 22""",102706,CDM,274,RC,L1830,HCPCS,,,Inpatient,,,54.4,,,,80,,43.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,42.27,percent of total billed charges,,,95,,51.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,51.68,
L3650 SLING & SWOTH UNIV ADULT,102708,CDM,274,RC,L3650,HCPCS,,,Outpatient,,,19.5,,,,80,,15.6,percent of total billed charges,,,,85,16.58,percent of total billed charges,,,77.7,,15.15,percent of total billed charges,,,95,,18.53,percent of total billed charges,,,60,,11.7,percent of total billed charges,,11.7,18.53,
L3650 SLING & SWOTH UNIV ADULT,102708,CDM,274,RC,L3650,HCPCS,,,Inpatient,,,19.5,,,,80,,15.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,15.15,percent of total billed charges,,,95,,18.53,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,18.53,
L1812 KNEE SPLINT HINGED SMALL,102709,CDM,274,RC,L1812,HCPCS,,,Outpatient,,,60.6,,,,80,,48.48,percent of total billed charges,,,,85,51.51,percent of total billed charges,,,77.7,,47.09,percent of total billed charges,,,95,,57.57,percent of total billed charges,,,60,,36.36,percent of total billed charges,,36.36,57.57,
L1812 KNEE SPLINT HINGED SMALL,102709,CDM,274,RC,L1812,HCPCS,,,Inpatient,,,60.6,,,,80,,48.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,47.09,percent of total billed charges,,,95,,57.57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,57.57,
HEEL PROTECTOR,102710,CDM,270,RC,,,,,Outpatient,,,16.1,,,,80,,12.88,percent of total billed charges,,,,85,13.69,percent of total billed charges,,,77.7,,12.51,percent of total billed charges,,,95,,15.3,percent of total billed charges,,,60,,9.66,percent of total billed charges,,9.66,15.3,
HEEL PROTECTOR,102710,CDM,270,RC,,,,,Inpatient,,,16.1,,,,80,,12.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.51,percent of total billed charges,,,95,,15.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.3,
HEMI SLING,102711,CDM,270,RC,,,,,Outpatient,,,234,,,,80,,187.2,percent of total billed charges,,,,85,198.9,percent of total billed charges,,,77.7,,181.82,percent of total billed charges,,,95,,222.3,percent of total billed charges,,,60,,140.4,percent of total billed charges,,140.4,222.3,
HEMI SLING,102711,CDM,270,RC,,,,,Inpatient,,,234,,,,80,,187.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,181.82,percent of total billed charges,,,95,,222.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,222.3,
"WRIST SPLINT UNIV RT 10""",102712,CDM,270,RC,,,,,Outpatient,,,28.4,,,,80,,22.72,percent of total billed charges,,,,85,24.14,percent of total billed charges,,,77.7,,22.07,percent of total billed charges,,,95,,26.98,percent of total billed charges,,,60,,17.04,percent of total billed charges,,17.04,26.98,
"WRIST SPLINT UNIV RT 10""",102712,CDM,270,RC,,,,,Inpatient,,,28.4,,,,80,,22.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,22.07,percent of total billed charges,,,95,,26.98,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,26.98,
ARM SLING SMALL PADDED,102714,CDM,270,RC,,,,,Outpatient,,,7.3,,,,80,,5.84,percent of total billed charges,,,,85,6.21,percent of total billed charges,,,77.7,,5.67,percent of total billed charges,,,95,,6.94,percent of total billed charges,,,60,,4.38,percent of total billed charges,,4.38,6.94,
ARM SLING SMALL PADDED,102714,CDM,270,RC,,,,,Inpatient,,,7.3,,,,80,,5.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.67,percent of total billed charges,,,95,,6.94,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.94,
ARM SLING MEDIUM PADDED,102715,CDM,270,RC,,,,,Outpatient,,,7.2,,,,80,,5.76,percent of total billed charges,,,,85,6.12,percent of total billed charges,,,77.7,,5.59,percent of total billed charges,,,95,,6.84,percent of total billed charges,,,60,,4.32,percent of total billed charges,,4.32,6.84,
ARM SLING MEDIUM PADDED,102715,CDM,270,RC,,,,,Inpatient,,,7.2,,,,80,,5.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.59,percent of total billed charges,,,95,,6.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.84,
ARM SLING LARGE PADDED,102716,CDM,270,RC,,,,,Outpatient,,,7.2,,,,80,,5.76,percent of total billed charges,,,,85,6.12,percent of total billed charges,,,77.7,,5.59,percent of total billed charges,,,95,,6.84,percent of total billed charges,,,60,,4.32,percent of total billed charges,,4.32,6.84,
ARM SLING LARGE PADDED,102716,CDM,270,RC,,,,,Inpatient,,,7.2,,,,80,,5.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.59,percent of total billed charges,,,95,,6.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.84,
L3660 SHOULDER IMMOBILIZER UNIV,102717,CDM,274,RC,L3660,HCPCS,,,Outpatient,,,18.8,,,,80,,15.04,percent of total billed charges,,,,50,50.63,fee schedule,,,77.7,,14.61,percent of total billed charges,,,95,,17.86,percent of total billed charges,,,60,,11.28,percent of total billed charges,,11.28,50.63,
L3660 SHOULDER IMMOBILIZER UNIV,102717,CDM,274,RC,L3660,HCPCS,,,Inpatient,,,18.8,,,,80,,15.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.61,percent of total billed charges,,,95,,17.86,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.86,
L1902 DELUXE ANKLE BRACE,102718,CDM,274,RC,L1902,HCPCS,,,Outpatient,,,40.4,,,,80,,32.32,percent of total billed charges,,,,85,34.34,percent of total billed charges,,,77.7,,31.39,percent of total billed charges,,,95,,38.38,percent of total billed charges,,,60,,24.24,percent of total billed charges,,24.24,38.38,
L1902 DELUXE ANKLE BRACE,102718,CDM,274,RC,L1902,HCPCS,,,Inpatient,,,40.4,,,,80,,32.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,31.39,percent of total billed charges,,,95,,38.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,38.38,
L4350 AIR ANKLE LARGE LEFT,102719,CDM,274,RC,L4350,HCPCS,,,Outpatient,,,57.6,,,,80,,46.08,percent of total billed charges,,,,85,48.96,percent of total billed charges,,,77.7,,44.76,percent of total billed charges,,,95,,54.72,percent of total billed charges,,,60,,34.56,percent of total billed charges,,34.56,54.72,
L4350 AIR ANKLE LARGE LEFT,102719,CDM,274,RC,L4350,HCPCS,,,Inpatient,,,57.6,,,,80,,46.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,44.76,percent of total billed charges,,,95,,54.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,54.72,
PATELLAR KNEE SUPPORT UNIV,102720,CDM,270,RC,,,,,Outpatient,,,39.9,,,,80,,31.92,percent of total billed charges,,,,85,33.92,percent of total billed charges,,,77.7,,31,percent of total billed charges,,,95,,37.91,percent of total billed charges,,,60,,23.94,percent of total billed charges,,23.94,37.91,
PATELLAR KNEE SUPPORT UNIV,102720,CDM,270,RC,,,,,Inpatient,,,39.9,,,,80,,31.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,31,percent of total billed charges,,,95,,37.91,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,37.91,
ANKLE BRACE/SUPPORT-NEOPRENE,102721,CDM,270,RC,,,,,Outpatient,,,25.2,,,,80,,20.16,percent of total billed charges,,,,85,21.42,percent of total billed charges,,,77.7,,19.58,percent of total billed charges,,,95,,23.94,percent of total billed charges,,,60,,15.12,percent of total billed charges,,15.12,23.94,
ANKLE BRACE/SUPPORT-NEOPRENE,102721,CDM,270,RC,,,,,Inpatient,,,25.2,,,,80,,20.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.58,percent of total billed charges,,,95,,23.94,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,23.94,
L4386 KNEE BRACE/FLEX LITE HINGED,102722,CDM,274,RC,L4386,HCPCS,,,Outpatient,,,42.9,,,,80,,34.32,percent of total billed charges,,,,85,36.47,percent of total billed charges,,,77.7,,33.33,percent of total billed charges,,,95,,40.76,percent of total billed charges,,,60,,25.74,percent of total billed charges,,25.74,40.76,
L4386 KNEE BRACE/FLEX LITE HINGED,102722,CDM,274,RC,L4386,HCPCS,,,Inpatient,,,42.9,,,,80,,34.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,33.33,percent of total billed charges,,,95,,40.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,40.76,
L4396 STATIC ANKLE FOOT ORTHOSIS,102724,CDM,274,RC,L4396,HCPCS,,,Outpatient,,,33.9,,,,80,,27.12,percent of total billed charges,,,,50,91.95,fee schedule,,,77.7,,26.34,percent of total billed charges,,,95,,32.21,percent of total billed charges,,,60,,20.34,percent of total billed charges,,20.34,91.95,
L4396 STATIC ANKLE FOOT ORTHOSIS,102724,CDM,274,RC,L4396,HCPCS,,,Inpatient,,,33.9,,,,80,,27.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,26.34,percent of total billed charges,,,95,,32.21,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,32.21,
COLLES SPLINT INFANT,102725,CDM,270,RC,,,,,Outpatient,,,17,,,,80,,13.6,percent of total billed charges,,,,85,14.45,percent of total billed charges,,,77.7,,13.21,percent of total billed charges,,,95,,16.15,percent of total billed charges,,,60,,10.2,percent of total billed charges,,10.2,16.15,
COLLES SPLINT INFANT,102725,CDM,270,RC,,,,,Inpatient,,,17,,,,80,,13.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,13.21,percent of total billed charges,,,95,,16.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,16.15,
TROCAR CATH,102728,CDM,270,RC,,,,,Outpatient,,,54,,,,80,,43.2,percent of total billed charges,,,,85,45.9,percent of total billed charges,,,77.7,,41.96,percent of total billed charges,,,95,,51.3,percent of total billed charges,,,60,,32.4,percent of total billed charges,,32.4,51.3,
TROCAR CATH,102728,CDM,270,RC,,,,,Inpatient,,,54,,,,80,,43.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,41.96,percent of total billed charges,,,95,,51.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,51.3,
CATHETER LEG STRAP REUSABLE DALE,102729,CDM,270,RC,,,,,Outpatient,,,4,,,,80,,3.2,percent of total billed charges,,,,85,3.4,percent of total billed charges,,,77.7,,3.11,percent of total billed charges,,,95,,3.8,percent of total billed charges,,,60,,2.4,percent of total billed charges,,2.4,3.8,
CATHETER LEG STRAP REUSABLE DALE,102729,CDM,270,RC,,,,,Inpatient,,,4,,,,80,,3.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.11,percent of total billed charges,,,95,,3.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.8,
CAUTERY PEN,102731,CDM,270,RC,,,,,Outpatient,,,36.4,,,,80,,29.12,percent of total billed charges,,,,85,30.94,percent of total billed charges,,,77.7,,28.28,percent of total billed charges,,,95,,34.58,percent of total billed charges,,,60,,21.84,percent of total billed charges,,21.84,34.58,
CAUTERY PEN,102731,CDM,270,RC,,,,,Inpatient,,,36.4,,,,80,,29.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,28.28,percent of total billed charges,,,95,,34.58,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,34.58,
MORGAN MEDI-FLOW LENS,102732,CDM,270,RC,,,,,Outpatient,,,162.9,,,,80,,130.32,percent of total billed charges,,,,85,138.47,percent of total billed charges,,,77.7,,126.57,percent of total billed charges,,,95,,154.76,percent of total billed charges,,,60,,97.74,percent of total billed charges,,97.74,154.76,
MORGAN MEDI-FLOW LENS,102732,CDM,270,RC,,,,,Inpatient,,,162.9,,,,80,,130.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,126.57,percent of total billed charges,,,95,,154.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,154.76,
CENTRAL VEIN CATH,102733,CDM,270,RC,,,,,Outpatient,,,79.8,,,,80,,63.84,percent of total billed charges,,,,85,67.83,percent of total billed charges,,,77.7,,62,percent of total billed charges,,,95,,75.81,percent of total billed charges,,,60,,47.88,percent of total billed charges,,47.88,75.81,
CENTRAL VEIN CATH,102733,CDM,270,RC,,,,,Inpatient,,,79.8,,,,80,,63.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,62,percent of total billed charges,,,95,,75.81,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,75.81,
FOLEY CATH 18FR 3 WAY,102734,CDM,270,RC,,,,,Outpatient,,,32.2,,,,80,,25.76,percent of total billed charges,,,,85,27.37,percent of total billed charges,,,77.7,,25.02,percent of total billed charges,,,95,,30.59,percent of total billed charges,,,60,,19.32,percent of total billed charges,,19.32,30.59,
FOLEY CATH 18FR 3 WAY,102734,CDM,270,RC,,,,,Inpatient,,,32.2,,,,80,,25.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,25.02,percent of total billed charges,,,95,,30.59,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,30.59,
COUDE CATHETER 18 FR,102735,CDM,270,RC,,,,,Outpatient,,,29.7,,,,80,,23.76,percent of total billed charges,,,,85,25.25,percent of total billed charges,,,77.7,,23.08,percent of total billed charges,,,95,,28.22,percent of total billed charges,,,60,,17.82,percent of total billed charges,,17.82,28.22,
COUDE CATHETER 18 FR,102735,CDM,270,RC,,,,,Inpatient,,,29.7,,,,80,,23.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,23.08,percent of total billed charges,,,95,,28.22,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,28.22,
MINOR LACERATION TRAY,102739,CDM,270,RC,,,,,Outpatient,,,0.1,,,,80,,0.08,percent of total billed charges,,,,85,0.09,percent of total billed charges,,,77.7,,0.08,percent of total billed charges,,,95,,0.1,percent of total billed charges,,,60,,0.06,percent of total billed charges,,0.06,0.1,
MINOR LACERATION TRAY,102739,CDM,270,RC,,,,,Inpatient,,,0.1,,,,80,,0.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.08,percent of total billed charges,,,95,,0.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,0.1,
ZZZSUCTION SET UP,102743,CDM,270,RC,,,,,Outpatient,,,0.1,,,,80,,0.08,percent of total billed charges,,,,85,0.09,percent of total billed charges,,,77.7,,0.08,percent of total billed charges,,,95,,0.1,percent of total billed charges,,,60,,0.06,percent of total billed charges,,0.06,0.1,
ZZZSUCTION SET UP,102743,CDM,270,RC,,,,,Inpatient,,,0.1,,,,80,,0.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.08,percent of total billed charges,,,95,,0.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,0.1,
OXYGEN SET UP,102744,CDM,270,RC,,,,,Outpatient,,,0.1,,,,80,,0.08,percent of total billed charges,,,,85,0.09,percent of total billed charges,,,77.7,,0.08,percent of total billed charges,,,95,,0.1,percent of total billed charges,,,60,,0.06,percent of total billed charges,,0.06,0.1,
OXYGEN SET UP,102744,CDM,270,RC,,,,,Inpatient,,,0.1,,,,80,,0.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.08,percent of total billed charges,,,95,,0.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,0.1,
SKIN STAPLER SMALL,102750,CDM,270,RC,,,,,Outpatient,,,14.4,,,,80,,11.52,percent of total billed charges,,,,85,12.24,percent of total billed charges,,,77.7,,11.19,percent of total billed charges,,,95,,13.68,percent of total billed charges,,,60,,8.64,percent of total billed charges,,8.64,13.68,
SKIN STAPLER SMALL,102750,CDM,270,RC,,,,,Inpatient,,,14.4,,,,80,,11.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.19,percent of total billed charges,,,95,,13.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.68,
THORACIC CATHETER 24 FR.,102752,CDM,270,RC,,,,,Outpatient,,,23.6,,,,80,,18.88,percent of total billed charges,,,,85,20.06,percent of total billed charges,,,77.7,,18.34,percent of total billed charges,,,95,,22.42,percent of total billed charges,,,60,,14.16,percent of total billed charges,,14.16,22.42,
THORACIC CATHETER 24 FR.,102752,CDM,270,RC,,,,,Inpatient,,,23.6,,,,80,,18.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,18.34,percent of total billed charges,,,95,,22.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,22.42,
SPLASH SHIELD,102753,CDM,270,RC,,,,,Outpatient,,,9.5,,,,80,,7.6,percent of total billed charges,,,,85,8.08,percent of total billed charges,,,77.7,,7.38,percent of total billed charges,,,95,,9.03,percent of total billed charges,,,60,,5.7,percent of total billed charges,,5.7,9.03,
SPLASH SHIELD,102753,CDM,270,RC,,,,,Inpatient,,,9.5,,,,80,,7.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.38,percent of total billed charges,,,95,,9.03,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.03,
SPINAL NEEDLE 25X 4 11-16,102757,CDM,270,RC,,,,,Outpatient,,,20.4,,,,80,,16.32,percent of total billed charges,,,,85,17.34,percent of total billed charges,,,77.7,,15.85,percent of total billed charges,,,95,,19.38,percent of total billed charges,,,60,,12.24,percent of total billed charges,,12.24,19.38,
SPINAL NEEDLE 25X 4 11-16,102757,CDM,270,RC,,,,,Inpatient,,,20.4,,,,80,,16.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,15.85,percent of total billed charges,,,95,,19.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,19.38,
FOLEY CATH KIT 16FR LATEX FREE SUB,102764,CDM,270,RC,,,,,Outpatient,,,38.7,,,,80,,30.96,percent of total billed charges,,,,85,32.9,percent of total billed charges,,,77.7,,30.07,percent of total billed charges,,,95,,36.77,percent of total billed charges,,,60,,23.22,percent of total billed charges,,23.22,36.77,
FOLEY CATH KIT 16FR LATEX FREE SUB,102764,CDM,270,RC,,,,,Inpatient,,,38.7,,,,80,,30.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,30.07,percent of total billed charges,,,95,,36.77,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,36.77,
PERINEAL COLD PACK,102767,CDM,270,RC,,,,,Outpatient,,,1.9,,,,80,,1.52,percent of total billed charges,,,,85,1.62,percent of total billed charges,,,77.7,,1.48,percent of total billed charges,,,95,,1.81,percent of total billed charges,,,60,,1.14,percent of total billed charges,,1.14,1.81,
PERINEAL COLD PACK,102767,CDM,270,RC,,,,,Inpatient,,,1.9,,,,80,,1.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.48,percent of total billed charges,,,95,,1.81,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.81,
AMNIOCENTESIS TRAY,102769,CDM,270,RC,,,,,Outpatient,,,59.3,,,,80,,47.44,percent of total billed charges,,,,85,50.41,percent of total billed charges,,,77.7,,46.08,percent of total billed charges,,,95,,56.34,percent of total billed charges,,,60,,35.58,percent of total billed charges,,35.58,56.34,
AMNIOCENTESIS TRAY,102769,CDM,270,RC,,,,,Inpatient,,,59.3,,,,80,,47.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,46.08,percent of total billed charges,,,95,,56.34,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,56.34,
EPIDURAL TRAY,102770,CDM,270,RC,,,,,Outpatient,,,78.8,,,,80,,63.04,percent of total billed charges,,,,85,66.98,percent of total billed charges,,,77.7,,61.23,percent of total billed charges,,,95,,74.86,percent of total billed charges,,,60,,47.28,percent of total billed charges,,47.28,74.86,
EPIDURAL TRAY,102770,CDM,270,RC,,,,,Inpatient,,,78.8,,,,80,,63.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,61.23,percent of total billed charges,,,95,,74.86,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,74.86,
CERVICAL COLLAR LG FORM FIT MED DENSITY,102771,CDM,270,RC,,,,,Outpatient,,,11.5,,,,80,,9.2,percent of total billed charges,,,,85,9.78,percent of total billed charges,,,77.7,,8.94,percent of total billed charges,,,95,,10.93,percent of total billed charges,,,60,,6.9,percent of total billed charges,,6.9,10.93,
CERVICAL COLLAR LG FORM FIT MED DENSITY,102771,CDM,270,RC,,,,,Inpatient,,,11.5,,,,80,,9.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.94,percent of total billed charges,,,95,,10.93,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.93,
EPIDURAL TRAY PERIFIX 17G,102772,CDM,270,RC,,,,,Outpatient,,,769.6,,,,80,,615.68,percent of total billed charges,,,,85,654.16,percent of total billed charges,,,77.7,,597.98,percent of total billed charges,,,95,,731.12,percent of total billed charges,,,60,,461.76,percent of total billed charges,,461.76,731.12,
EPIDURAL TRAY PERIFIX 17G,102772,CDM,270,RC,,,,,Inpatient,,,769.6,,,,80,,615.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,597.98,percent of total billed charges,,,95,,731.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,731.12,
L3260 HEALING SHOE SMALL,102774,CDM,274,RC,L3260,HCPCS,,,Outpatient,,,18.3,,,,80,,14.64,percent of total billed charges,,,,85,15.56,percent of total billed charges,,,77.7,,14.22,percent of total billed charges,,,95,,17.39,percent of total billed charges,,,60,,10.98,percent of total billed charges,,10.98,17.39,
L3260 HEALING SHOE SMALL,102774,CDM,274,RC,L3260,HCPCS,,,Inpatient,,,18.3,,,,80,,14.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.22,percent of total billed charges,,,95,,17.39,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.39,
EAR SYRINGE,102775,CDM,270,RC,,,,,Outpatient,,,2.1,,,,80,,1.68,percent of total billed charges,,,,85,1.79,percent of total billed charges,,,77.7,,1.63,percent of total billed charges,,,95,,2,percent of total billed charges,,,60,,1.26,percent of total billed charges,,1.26,2,
EAR SYRINGE,102775,CDM,270,RC,,,,,Inpatient,,,2.1,,,,80,,1.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.63,percent of total billed charges,,,95,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2,
UMBILICAL CATH 5.0 FR,102776,CDM,270,RC,,,,,Outpatient,,,49.4,,,,80,,39.52,percent of total billed charges,,,,85,41.99,percent of total billed charges,,,77.7,,38.38,percent of total billed charges,,,95,,46.93,percent of total billed charges,,,60,,29.64,percent of total billed charges,,29.64,46.93,
UMBILICAL CATH 5.0 FR,102776,CDM,270,RC,,,,,Inpatient,,,49.4,,,,80,,39.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,38.38,percent of total billed charges,,,95,,46.93,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,46.93,
ANESTHESIA MASK CHILD/SM ADULT,102777,CDM,270,RC,,,,,Outpatient,,,4.9,,,,80,,3.92,percent of total billed charges,,,,85,4.17,percent of total billed charges,,,77.7,,3.81,percent of total billed charges,,,95,,4.66,percent of total billed charges,,,60,,2.94,percent of total billed charges,,2.94,4.66,
ANESTHESIA MASK CHILD/SM ADULT,102777,CDM,270,RC,,,,,Inpatient,,,4.9,,,,80,,3.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.81,percent of total billed charges,,,95,,4.66,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.66,
FOLEY CATHETER 18F 5CC,102778,CDM,270,RC,,,,,Outpatient,,,10.7,,,,80,,8.56,percent of total billed charges,,,,85,9.1,percent of total billed charges,,,77.7,,8.31,percent of total billed charges,,,95,,10.17,percent of total billed charges,,,60,,6.42,percent of total billed charges,,6.42,10.17,
FOLEY CATHETER 18F 5CC,102778,CDM,270,RC,,,,,Inpatient,,,10.7,,,,80,,8.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.31,percent of total billed charges,,,95,,10.17,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.17,
EPIDURAL CANNULA,102779,CDM,270,RC,,,,,Outpatient,,,17.8,,,,80,,14.24,percent of total billed charges,,,,85,15.13,percent of total billed charges,,,77.7,,13.83,percent of total billed charges,,,95,,16.91,percent of total billed charges,,,60,,10.68,percent of total billed charges,,10.68,16.91,
EPIDURAL CANNULA,102779,CDM,270,RC,,,,,Inpatient,,,17.8,,,,80,,14.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,13.83,percent of total billed charges,,,95,,16.91,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,16.91,
EXTERNAL CATH TEXAS,102780,CDM,270,RC,,,,,Outpatient,,,4.1,,,,80,,3.28,percent of total billed charges,,,,85,3.49,percent of total billed charges,,,77.7,,3.19,percent of total billed charges,,,95,,3.9,percent of total billed charges,,,60,,2.46,percent of total billed charges,,2.46,3.9,
EXTERNAL CATH TEXAS,102780,CDM,270,RC,,,,,Inpatient,,,4.1,,,,80,,3.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.19,percent of total billed charges,,,95,,3.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.9,
DAVOL CATH 14 FR,102781,CDM,270,RC,,,,,Outpatient,,,2.6,,,,80,,2.08,percent of total billed charges,,,,85,2.21,percent of total billed charges,,,77.7,,2.02,percent of total billed charges,,,95,,2.47,percent of total billed charges,,,60,,1.56,percent of total billed charges,,1.56,2.47,
DAVOL CATH 14 FR,102781,CDM,270,RC,,,,,Inpatient,,,2.6,,,,80,,2.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.02,percent of total billed charges,,,95,,2.47,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.47,
CLAVE EXT SET MINIBORE,102782,CDM,270,RC,,,,,Outpatient,,,10.5,,,,80,,8.4,percent of total billed charges,,,,85,8.93,percent of total billed charges,,,77.7,,8.16,percent of total billed charges,,,95,,9.98,percent of total billed charges,,,60,,6.3,percent of total billed charges,,6.3,9.98,
CLAVE EXT SET MINIBORE,102782,CDM,270,RC,,,,,Inpatient,,,10.5,,,,80,,8.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.16,percent of total billed charges,,,95,,9.98,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.98,
L3809 WRIST SPLINT PED LT,102783,CDM,274,RC,L3809,HCPCS,,,Outpatient,,,12.2,,,,80,,9.76,percent of total billed charges,,,,85,10.37,percent of total billed charges,,,77.7,,9.48,percent of total billed charges,,,95,,11.59,percent of total billed charges,,,60,,7.32,percent of total billed charges,,7.32,11.59,
L3809 WRIST SPLINT PED LT,102783,CDM,274,RC,L3809,HCPCS,,,Inpatient,,,12.2,,,,80,,9.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.48,percent of total billed charges,,,95,,11.59,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.59,
L3650 CLAVICLE SPLINT XLG,102784,CDM,274,RC,L3650,HCPCS,,,Outpatient,,,13.9,,,,80,,11.12,percent of total billed charges,,,,85,11.82,percent of total billed charges,,,77.7,,10.8,percent of total billed charges,,,95,,13.21,percent of total billed charges,,,60,,8.34,percent of total billed charges,,8.34,13.21,
L3650 CLAVICLE SPLINT XLG,102784,CDM,274,RC,L3650,HCPCS,,,Inpatient,,,13.9,,,,80,,11.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.8,percent of total billed charges,,,95,,13.21,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.21,
ARM SLING XLARGE PADDED,102785,CDM,270,RC,,,,,Outpatient,,,7.2,,,,80,,5.76,percent of total billed charges,,,,85,6.12,percent of total billed charges,,,77.7,,5.59,percent of total billed charges,,,95,,6.84,percent of total billed charges,,,60,,4.32,percent of total billed charges,,4.32,6.84,
ARM SLING XLARGE PADDED,102785,CDM,270,RC,,,,,Inpatient,,,7.2,,,,80,,5.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.59,percent of total billed charges,,,95,,6.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.84,
MISTY NEB WITH MASK,102788,CDM,270,RC,,,,,Outpatient,,,3.3,,,,80,,2.64,percent of total billed charges,,,,85,2.81,percent of total billed charges,,,77.7,,2.56,percent of total billed charges,,,95,,3.14,percent of total billed charges,,,60,,1.98,percent of total billed charges,,1.98,3.14,
MISTY NEB WITH MASK,102788,CDM,270,RC,,,,,Inpatient,,,3.3,,,,80,,2.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.56,percent of total billed charges,,,95,,3.14,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.14,
OB VACUUM EXTRACTOR,102789,CDM,270,RC,,,,,Outpatient,,,171.8,,,,80,,137.44,percent of total billed charges,,,,85,146.03,percent of total billed charges,,,77.7,,133.49,percent of total billed charges,,,95,,163.21,percent of total billed charges,,,60,,103.08,percent of total billed charges,,103.08,163.21,
OB VACUUM EXTRACTOR,102789,CDM,270,RC,,,,,Inpatient,,,171.8,,,,80,,137.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,133.49,percent of total billed charges,,,95,,163.21,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,163.21,
VAGINAL PACKING,102791,CDM,270,RC,,,,,Outpatient,,,10.9,,,,80,,8.72,percent of total billed charges,,,,85,9.27,percent of total billed charges,,,77.7,,8.47,percent of total billed charges,,,95,,10.36,percent of total billed charges,,,60,,6.54,percent of total billed charges,,6.54,10.36,
VAGINAL PACKING,102791,CDM,270,RC,,,,,Inpatient,,,10.9,,,,80,,8.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.47,percent of total billed charges,,,95,,10.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.36,
SENSORTIP TRANSDUCER,102793,CDM,270,RC,,,,,Outpatient,,,83.6,,,,80,,66.88,percent of total billed charges,,,,85,71.06,percent of total billed charges,,,77.7,,64.96,percent of total billed charges,,,95,,79.42,percent of total billed charges,,,60,,50.16,percent of total billed charges,,50.16,79.42,
SENSORTIP TRANSDUCER,102793,CDM,270,RC,,,,,Inpatient,,,83.6,,,,80,,66.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,64.96,percent of total billed charges,,,95,,79.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,79.42,
SPIRAL ELECTRODES,102794,CDM,270,RC,,,,,Outpatient,,,13.7,,,,80,,10.96,percent of total billed charges,,,,85,11.65,percent of total billed charges,,,77.7,,10.64,percent of total billed charges,,,95,,13.02,percent of total billed charges,,,60,,8.22,percent of total billed charges,,8.22,13.02,
SPIRAL ELECTRODES,102794,CDM,270,RC,,,,,Inpatient,,,13.7,,,,80,,10.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.64,percent of total billed charges,,,95,,13.02,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.02,
FOLEY CATH 20FR 3OCC 3WAY,102796,CDM,270,RC,,,,,Outpatient,,,16,,,,80,,12.8,percent of total billed charges,,,,85,13.6,percent of total billed charges,,,77.7,,12.43,percent of total billed charges,,,95,,15.2,percent of total billed charges,,,60,,9.6,percent of total billed charges,,9.6,15.2,
FOLEY CATH 20FR 3OCC 3WAY,102796,CDM,270,RC,,,,,Inpatient,,,16,,,,80,,12.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.43,percent of total billed charges,,,95,,15.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.2,
PUDENAL TRAY,102797,CDM,270,RC,,,,,Outpatient,,,61.3,,,,80,,49.04,percent of total billed charges,,,,85,52.11,percent of total billed charges,,,77.7,,47.63,percent of total billed charges,,,95,,58.24,percent of total billed charges,,,60,,36.78,percent of total billed charges,,36.78,58.24,
PUDENAL TRAY,102797,CDM,270,RC,,,,,Inpatient,,,61.3,,,,80,,49.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,47.63,percent of total billed charges,,,95,,58.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,58.24,
LOCAL SET,102798,CDM,270,RC,,,,,Outpatient,,,0.1,,,,80,,0.08,percent of total billed charges,,,,85,0.09,percent of total billed charges,,,77.7,,0.08,percent of total billed charges,,,95,,0.1,percent of total billed charges,,,60,,0.06,percent of total billed charges,,0.06,0.1,
LOCAL SET,102798,CDM,270,RC,,,,,Inpatient,,,0.1,,,,80,,0.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.08,percent of total billed charges,,,95,,0.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,0.1,
AMNIHOOK,102799,CDM,270,RC,,,,,Outpatient,,,2.3,,,,80,,1.84,percent of total billed charges,,,,85,1.96,percent of total billed charges,,,77.7,,1.79,percent of total billed charges,,,95,,2.19,percent of total billed charges,,,60,,1.38,percent of total billed charges,,1.38,2.19,
AMNIHOOK,102799,CDM,270,RC,,,,,Inpatient,,,2.3,,,,80,,1.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.79,percent of total billed charges,,,95,,2.19,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.19,
MECONIUM ASPIRATOR,102800,CDM,270,RC,,,,,Outpatient,,,13,,,,80,,10.4,percent of total billed charges,,,,85,11.05,percent of total billed charges,,,77.7,,10.1,percent of total billed charges,,,95,,12.35,percent of total billed charges,,,60,,7.8,percent of total billed charges,,7.8,12.35,
MECONIUM ASPIRATOR,102800,CDM,270,RC,,,,,Inpatient,,,13,,,,80,,10.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.1,percent of total billed charges,,,95,,12.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,12.35,
THORACIC CATHETER 28FR,102801,CDM,270,RC,,,,,Outpatient,,,16.3,,,,80,,13.04,percent of total billed charges,,,,85,13.86,percent of total billed charges,,,77.7,,12.67,percent of total billed charges,,,95,,15.49,percent of total billed charges,,,60,,9.78,percent of total billed charges,,9.78,15.49,
THORACIC CATHETER 28FR,102801,CDM,270,RC,,,,,Inpatient,,,16.3,,,,80,,13.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.67,percent of total billed charges,,,95,,15.49,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.49,
INTUBATING 6FR STYLETTE,102804,CDM,270,RC,,,,,Outpatient,,,6.1,,,,80,,4.88,percent of total billed charges,,,,85,5.19,percent of total billed charges,,,77.7,,4.74,percent of total billed charges,,,95,,5.8,percent of total billed charges,,,60,,3.66,percent of total billed charges,,3.66,5.8,
INTUBATING 6FR STYLETTE,102804,CDM,270,RC,,,,,Inpatient,,,6.1,,,,80,,4.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.74,percent of total billed charges,,,95,,5.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.8,
ENDOTRACH TUBE 7.5 CUFFED,102805,CDM,270,RC,,,,,Outpatient,,,4.5,,,,80,,3.6,percent of total billed charges,,,,85,3.83,percent of total billed charges,,,77.7,,3.5,percent of total billed charges,,,95,,4.28,percent of total billed charges,,,60,,2.7,percent of total billed charges,,2.7,4.28,
ENDOTRACH TUBE 7.5 CUFFED,102805,CDM,270,RC,,,,,Inpatient,,,4.5,,,,80,,3.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.5,percent of total billed charges,,,95,,4.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.28,
RADIOPAQUE SPONGES 4X4 16 PLY ST,102813,CDM,270,RC,,,,,Outpatient,,,0.5,,,,80,,0.4,percent of total billed charges,,,,85,0.43,percent of total billed charges,,,77.7,,0.39,percent of total billed charges,,,95,,0.48,percent of total billed charges,,,60,,0.3,percent of total billed charges,,0.3,0.48,
RADIOPAQUE SPONGES 4X4 16 PLY ST,102813,CDM,270,RC,,,,,Inpatient,,,0.5,,,,80,,0.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.39,percent of total billed charges,,,95,,0.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,0.48,
AIRWAY ORAL 80MM GREEN,102814,CDM,270,RC,,,,,Outpatient,,,0.8,,,,80,,0.64,percent of total billed charges,,,,85,0.68,percent of total billed charges,,,77.7,,0.62,percent of total billed charges,,,95,,0.76,percent of total billed charges,,,60,,0.48,percent of total billed charges,,0.48,0.76,
AIRWAY ORAL 80MM GREEN,102814,CDM,270,RC,,,,,Inpatient,,,0.8,,,,80,,0.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.62,percent of total billed charges,,,95,,0.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,0.76,
AIRWAY ORAL 70MM WHITE,102815,CDM,270,RC,,,,,Outpatient,,,0.8,,,,80,,0.64,percent of total billed charges,,,,85,0.68,percent of total billed charges,,,77.7,,0.62,percent of total billed charges,,,95,,0.76,percent of total billed charges,,,60,,0.48,percent of total billed charges,,0.48,0.76,
AIRWAY ORAL 70MM WHITE,102815,CDM,270,RC,,,,,Inpatient,,,0.8,,,,80,,0.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.62,percent of total billed charges,,,95,,0.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,0.76,
AIRWAY ORAL 40MM,102816,CDM,270,RC,,,,,Outpatient,,,0.6,,,,80,,0.48,percent of total billed charges,,,,85,0.51,percent of total billed charges,,,77.7,,0.47,percent of total billed charges,,,95,,0.57,percent of total billed charges,,,60,,0.36,percent of total billed charges,,0.36,0.57,
AIRWAY ORAL 40MM,102816,CDM,270,RC,,,,,Inpatient,,,0.6,,,,80,,0.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.47,percent of total billed charges,,,95,,0.57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,0.57,
NASAL AIRWAY,102819,CDM,270,RC,,,,,Outpatient,,,9.6,,,,80,,7.68,percent of total billed charges,,,,85,8.16,percent of total billed charges,,,77.7,,7.46,percent of total billed charges,,,95,,9.12,percent of total billed charges,,,60,,5.76,percent of total billed charges,,5.76,9.12,
NASAL AIRWAY,102819,CDM,270,RC,,,,,Inpatient,,,9.6,,,,80,,7.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.46,percent of total billed charges,,,95,,9.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.12,
CAST BOOT XL,102821,CDM,270,RC,,,,,Outpatient,,,1.9,,,,80,,1.52,percent of total billed charges,,,,85,1.62,percent of total billed charges,,,77.7,,1.48,percent of total billed charges,,,95,,1.81,percent of total billed charges,,,60,,1.14,percent of total billed charges,,1.14,1.81,
CAST BOOT XL,102821,CDM,270,RC,,,,,Inpatient,,,1.9,,,,80,,1.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.48,percent of total billed charges,,,95,,1.81,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.81,
L3260 HEALING SHOE PED,102822,CDM,274,RC,L3260,HCPCS,,,Outpatient,,,12.5,,,,80,,10,percent of total billed charges,,,,85,10.63,percent of total billed charges,,,77.7,,9.71,percent of total billed charges,,,95,,11.88,percent of total billed charges,,,60,,7.5,percent of total billed charges,,7.5,11.88,
L3260 HEALING SHOE PED,102822,CDM,274,RC,L3260,HCPCS,,,Inpatient,,,12.5,,,,80,,10,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.71,percent of total billed charges,,,95,,11.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.88,
PED ANESTHESIA CIRCUIT,102823,CDM,270,RC,,,,,Outpatient,,,16,,,,80,,12.8,percent of total billed charges,,,,85,13.6,percent of total billed charges,,,77.7,,12.43,percent of total billed charges,,,95,,15.2,percent of total billed charges,,,60,,9.6,percent of total billed charges,,9.6,15.2,
PED ANESTHESIA CIRCUIT,102823,CDM,270,RC,,,,,Inpatient,,,16,,,,80,,12.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.43,percent of total billed charges,,,95,,15.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.2,
ANESTHESIA MASK- MED,102824,CDM,270,RC,,,,,Outpatient,,,5.8,,,,80,,4.64,percent of total billed charges,,,,85,4.93,percent of total billed charges,,,77.7,,4.51,percent of total billed charges,,,95,,5.51,percent of total billed charges,,,60,,3.48,percent of total billed charges,,3.48,5.51,
ANESTHESIA MASK- MED,102824,CDM,270,RC,,,,,Inpatient,,,5.8,,,,80,,4.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.51,percent of total billed charges,,,95,,5.51,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.51,
"ANESTHESIA CIRC ADULT 60""W/ETCO2",102826,CDM,270,RC,,,,,Outpatient,,,21.4,,,,80,,17.12,percent of total billed charges,,,,85,18.19,percent of total billed charges,,,77.7,,16.63,percent of total billed charges,,,95,,20.33,percent of total billed charges,,,60,,12.84,percent of total billed charges,,12.84,20.33,
"ANESTHESIA CIRC ADULT 60""W/ETCO2",102826,CDM,270,RC,,,,,Inpatient,,,21.4,,,,80,,17.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,16.63,percent of total billed charges,,,95,,20.33,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,20.33,
EKG BACK PAD,102827,CDM,270,RC,,,,,Outpatient,,,10.6,,,,80,,8.48,percent of total billed charges,,,,85,9.01,percent of total billed charges,,,77.7,,8.24,percent of total billed charges,,,95,,10.07,percent of total billed charges,,,60,,6.36,percent of total billed charges,,6.36,10.07,
EKG BACK PAD,102827,CDM,270,RC,,,,,Inpatient,,,10.6,,,,80,,8.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.24,percent of total billed charges,,,95,,10.07,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.07,
EKG BACK PAD - INFANT,102828,CDM,270,RC,,,,,Outpatient,,,8.1,,,,80,,6.48,percent of total billed charges,,,,85,6.89,percent of total billed charges,,,77.7,,6.29,percent of total billed charges,,,95,,7.7,percent of total billed charges,,,60,,4.86,percent of total billed charges,,4.86,7.7,
EKG BACK PAD - INFANT,102828,CDM,270,RC,,,,,Inpatient,,,8.1,,,,80,,6.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.29,percent of total billed charges,,,95,,7.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.7,
FOLEY CATHETER 16F 5CC,102829,CDM,270,RC,,,,,Outpatient,,,11.4,,,,80,,9.12,percent of total billed charges,,,,85,9.69,percent of total billed charges,,,77.7,,8.86,percent of total billed charges,,,95,,10.83,percent of total billed charges,,,60,,6.84,percent of total billed charges,,6.84,10.83,
FOLEY CATHETER 16F 5CC,102829,CDM,270,RC,,,,,Inpatient,,,11.4,,,,80,,9.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.86,percent of total billed charges,,,95,,10.83,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.83,
EXTERNAL CATHETER LG,102830,CDM,270,RC,,,,,Outpatient,,,4.4,,,,80,,3.52,percent of total billed charges,,,,85,3.74,percent of total billed charges,,,77.7,,3.42,percent of total billed charges,,,95,,4.18,percent of total billed charges,,,60,,2.64,percent of total billed charges,,2.64,4.18,
EXTERNAL CATHETER LG,102830,CDM,270,RC,,,,,Inpatient,,,4.4,,,,80,,3.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.42,percent of total billed charges,,,95,,4.18,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.18,
DAVOL CATH 16FR,102831,CDM,270,RC,,,,,Outpatient,,,2.9,,,,80,,2.32,percent of total billed charges,,,,85,2.47,percent of total billed charges,,,77.7,,2.25,percent of total billed charges,,,95,,2.76,percent of total billed charges,,,60,,1.74,percent of total billed charges,,1.74,2.76,
DAVOL CATH 16FR,102831,CDM,270,RC,,,,,Inpatient,,,2.9,,,,80,,2.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.25,percent of total billed charges,,,95,,2.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.76,
WRIST SPLINT PED RT,102832,CDM,270,RC,,,,,Outpatient,,,12.2,,,,80,,9.76,percent of total billed charges,,,,85,10.37,percent of total billed charges,,,77.7,,9.48,percent of total billed charges,,,95,,11.59,percent of total billed charges,,,60,,7.32,percent of total billed charges,,7.32,11.59,
WRIST SPLINT PED RT,102832,CDM,270,RC,,,,,Inpatient,,,12.2,,,,80,,9.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.48,percent of total billed charges,,,95,,11.59,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.59,
L3650 CLAVICLE SPLINT MED,102833,CDM,274,RC,L3650,HCPCS,,,Outpatient,,,13.9,,,,80,,11.12,percent of total billed charges,,,,85,11.82,percent of total billed charges,,,77.7,,10.8,percent of total billed charges,,,95,,13.21,percent of total billed charges,,,60,,8.34,percent of total billed charges,,8.34,13.21,
L3650 CLAVICLE SPLINT MED,102833,CDM,274,RC,L3650,HCPCS,,,Inpatient,,,13.9,,,,80,,11.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.8,percent of total billed charges,,,95,,13.21,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.21,
SKIN STAPLER WIDE,102835,CDM,270,RC,,,,,Outpatient,,,24.5,,,,80,,19.6,percent of total billed charges,,,,85,20.83,percent of total billed charges,,,77.7,,19.04,percent of total billed charges,,,95,,23.28,percent of total billed charges,,,60,,14.7,percent of total billed charges,,14.7,23.28,
SKIN STAPLER WIDE,102835,CDM,270,RC,,,,,Inpatient,,,24.5,,,,80,,19.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.04,percent of total billed charges,,,95,,23.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,23.28,
NELCOR AIRWAY ADAPTER,102836,CDM,270,RC,,,,,Outpatient,,,29.1,,,,80,,23.28,percent of total billed charges,,,,85,24.74,percent of total billed charges,,,77.7,,22.61,percent of total billed charges,,,95,,27.65,percent of total billed charges,,,60,,17.46,percent of total billed charges,,17.46,27.65,
NELCOR AIRWAY ADAPTER,102836,CDM,270,RC,,,,,Inpatient,,,29.1,,,,80,,23.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,22.61,percent of total billed charges,,,95,,27.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,27.65,
ACCURA NEEDLE COUNTER,102837,CDM,270,RC,,,,,Outpatient,,,3.1,,,,80,,2.48,percent of total billed charges,,,,85,2.64,percent of total billed charges,,,77.7,,2.41,percent of total billed charges,,,95,,2.95,percent of total billed charges,,,60,,1.86,percent of total billed charges,,1.86,2.95,
ACCURA NEEDLE COUNTER,102837,CDM,270,RC,,,,,Inpatient,,,3.1,,,,80,,2.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.41,percent of total billed charges,,,95,,2.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.95,
ELECTROSURGICAL PEN,102838,CDM,270,RC,,,,,Outpatient,,,11.6,,,,80,,9.28,percent of total billed charges,,,,85,9.86,percent of total billed charges,,,77.7,,9.01,percent of total billed charges,,,95,,11.02,percent of total billed charges,,,60,,6.96,percent of total billed charges,,6.96,11.02,
ELECTROSURGICAL PEN,102838,CDM,270,RC,,,,,Inpatient,,,11.6,,,,80,,9.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.01,percent of total billed charges,,,95,,11.02,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.02,
DISPERSIVE GROUND ADULT,102839,CDM,270,RC,,,,,Outpatient,,,11,,,,80,,8.8,percent of total billed charges,,,,85,9.35,percent of total billed charges,,,77.7,,8.55,percent of total billed charges,,,95,,10.45,percent of total billed charges,,,60,,6.6,percent of total billed charges,,6.6,10.45,
DISPERSIVE GROUND ADULT,102839,CDM,270,RC,,,,,Inpatient,,,11,,,,80,,8.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.55,percent of total billed charges,,,95,,10.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.45,
ESOPHAGEAL STETHOSCOPE W/TEMP,102840,CDM,270,RC,,,,,Outpatient,,,11.6,,,,80,,9.28,percent of total billed charges,,,,85,9.86,percent of total billed charges,,,77.7,,9.01,percent of total billed charges,,,95,,11.02,percent of total billed charges,,,60,,6.96,percent of total billed charges,,6.96,11.02,
ESOPHAGEAL STETHOSCOPE W/TEMP,102840,CDM,270,RC,,,,,Inpatient,,,11.6,,,,80,,9.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.01,percent of total billed charges,,,95,,11.02,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.02,
VENTILATOR HOSE,102841,CDM,270,RC,,,,,Outpatient,,,7.3,,,,80,,5.84,percent of total billed charges,,,,85,6.21,percent of total billed charges,,,77.7,,5.67,percent of total billed charges,,,95,,6.94,percent of total billed charges,,,60,,4.38,percent of total billed charges,,4.38,6.94,
VENTILATOR HOSE,102841,CDM,270,RC,,,,,Inpatient,,,7.3,,,,80,,5.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.67,percent of total billed charges,,,95,,6.94,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.94,
INSUFFLATION NEEDLE,102842,CDM,270,RC,,,,,Outpatient,,,59.8,,,,80,,47.84,percent of total billed charges,,,,85,50.83,percent of total billed charges,,,77.7,,46.46,percent of total billed charges,,,95,,56.81,percent of total billed charges,,,60,,35.88,percent of total billed charges,,35.88,56.81,
INSUFFLATION NEEDLE,102842,CDM,270,RC,,,,,Inpatient,,,59.8,,,,80,,47.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,46.46,percent of total billed charges,,,95,,56.81,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,56.81,
O2 TUBING,102843,CDM,270,RC,,,,,Outpatient,,,93.6,,,,80,,74.88,percent of total billed charges,,,,85,79.56,percent of total billed charges,,,77.7,,72.73,percent of total billed charges,,,95,,88.92,percent of total billed charges,,,60,,56.16,percent of total billed charges,,56.16,88.92,
O2 TUBING,102843,CDM,270,RC,,,,,Inpatient,,,93.6,,,,80,,74.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,72.73,percent of total billed charges,,,95,,88.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,88.92,
SPINAL ANESTHESIA TRAY,102844,CDM,270,RC,,,,,Outpatient,,,40.4,,,,80,,32.32,percent of total billed charges,,,,85,34.34,percent of total billed charges,,,77.7,,31.39,percent of total billed charges,,,95,,38.38,percent of total billed charges,,,60,,24.24,percent of total billed charges,,24.24,38.38,
SPINAL ANESTHESIA TRAY,102844,CDM,270,RC,,,,,Inpatient,,,40.4,,,,80,,32.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,31.39,percent of total billed charges,,,95,,38.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,38.38,
DURAPREP,102845,CDM,270,RC,,,,,Outpatient,,,14.7,,,,80,,11.76,percent of total billed charges,,,,85,12.5,percent of total billed charges,,,77.7,,11.42,percent of total billed charges,,,95,,13.97,percent of total billed charges,,,60,,8.82,percent of total billed charges,,8.82,13.97,
DURAPREP,102845,CDM,270,RC,,,,,Inpatient,,,14.7,,,,80,,11.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.42,percent of total billed charges,,,95,,13.97,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.97,
ANTIFOG WITH SPONGE,102846,CDM,270,RC,,,,,Outpatient,,,3.6,,,,80,,2.88,percent of total billed charges,,,,85,3.06,percent of total billed charges,,,77.7,,2.8,percent of total billed charges,,,95,,3.42,percent of total billed charges,,,60,,2.16,percent of total billed charges,,2.16,3.42,
ANTIFOG WITH SPONGE,102846,CDM,270,RC,,,,,Inpatient,,,3.6,,,,80,,2.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.8,percent of total billed charges,,,95,,3.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.42,
SUCTION CANISTER,102847,CDM,270,RC,,,,,Outpatient,,,4.8,,,,80,,3.84,percent of total billed charges,,,,85,4.08,percent of total billed charges,,,77.7,,3.73,percent of total billed charges,,,95,,4.56,percent of total billed charges,,,60,,2.88,percent of total billed charges,,2.88,4.56,
SUCTION CANISTER,102847,CDM,270,RC,,,,,Inpatient,,,4.8,,,,80,,3.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.73,percent of total billed charges,,,95,,4.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.56,
POOLE SUCTION W/TUBING,102848,CDM,270,RC,,,,,Outpatient,,,9.8,,,,80,,7.84,percent of total billed charges,,,,85,8.33,percent of total billed charges,,,77.7,,7.61,percent of total billed charges,,,95,,9.31,percent of total billed charges,,,60,,5.88,percent of total billed charges,,5.88,9.31,
POOLE SUCTION W/TUBING,102848,CDM,270,RC,,,,,Inpatient,,,9.8,,,,80,,7.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.61,percent of total billed charges,,,95,,9.31,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.31,
POLYP TRAP 4 CHAMBER FIXED,102849,CDM,270,RC,,,,,Outpatient,,,27.5,,,,80,,22,percent of total billed charges,,,,85,23.38,percent of total billed charges,,,77.7,,21.37,percent of total billed charges,,,95,,26.13,percent of total billed charges,,,60,,16.5,percent of total billed charges,,16.5,26.13,
POLYP TRAP 4 CHAMBER FIXED,102849,CDM,270,RC,,,,,Inpatient,,,27.5,,,,80,,22,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,21.37,percent of total billed charges,,,95,,26.13,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,26.13,
STAT TEMP DOT II,102850,CDM,270,RC,,,,,Outpatient,,,1.6,,,,80,,1.28,percent of total billed charges,,,,85,1.36,percent of total billed charges,,,77.7,,1.24,percent of total billed charges,,,95,,1.52,percent of total billed charges,,,60,,0.96,percent of total billed charges,,0.96,1.52,
STAT TEMP DOT II,102850,CDM,270,RC,,,,,Inpatient,,,1.6,,,,80,,1.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.24,percent of total billed charges,,,95,,1.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.52,
J-VAC,102852,CDM,270,RC,,,,,Outpatient,,,96.5,,,,80,,77.2,percent of total billed charges,,,,85,82.03,percent of total billed charges,,,77.7,,74.98,percent of total billed charges,,,95,,91.68,percent of total billed charges,,,60,,57.9,percent of total billed charges,,57.9,91.68,
J-VAC,102852,CDM,270,RC,,,,,Inpatient,,,96.5,,,,80,,77.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,74.98,percent of total billed charges,,,95,,91.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,91.68,
BLAKE DRAIN 15 FR,102853,CDM,270,RC,,,,,Outpatient,,,67.5,,,,80,,54,percent of total billed charges,,,,85,57.38,percent of total billed charges,,,77.7,,52.45,percent of total billed charges,,,95,,64.13,percent of total billed charges,,,60,,40.5,percent of total billed charges,,40.5,64.13,
BLAKE DRAIN 15 FR,102853,CDM,270,RC,,,,,Inpatient,,,67.5,,,,80,,54,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,52.45,percent of total billed charges,,,95,,64.13,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,64.13,
BLAKE DRAIN 19 FR,102854,CDM,270,RC,,,,,Outpatient,,,78,,,,80,,62.4,percent of total billed charges,,,,85,66.3,percent of total billed charges,,,77.7,,60.61,percent of total billed charges,,,95,,74.1,percent of total billed charges,,,60,,46.8,percent of total billed charges,,46.8,74.1,
BLAKE DRAIN 19 FR,102854,CDM,270,RC,,,,,Inpatient,,,78,,,,80,,62.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,60.61,percent of total billed charges,,,95,,74.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,74.1,
MULTIFIRE GIA 60-3.8 STAPLER,102855,CDM,270,RC,,,,,Outpatient,,,353,,,,80,,282.4,percent of total billed charges,,,,85,300.05,percent of total billed charges,,,77.7,,274.28,percent of total billed charges,,,95,,335.35,percent of total billed charges,,,60,,211.8,percent of total billed charges,,211.8,335.35,
MULTIFIRE GIA 60-3.8 STAPLER,102855,CDM,270,RC,,,,,Inpatient,,,353,,,,80,,282.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,274.28,percent of total billed charges,,,95,,335.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,335.35,
SCD SLEEVE THIGH HIGH,102856,CDM,270,RC,,,,,Outpatient,,,155.8,,,,80,,124.64,percent of total billed charges,,,,85,132.43,percent of total billed charges,,,77.7,,121.06,percent of total billed charges,,,95,,148.01,percent of total billed charges,,,60,,93.48,percent of total billed charges,,93.48,148.01,
SCD SLEEVE THIGH HIGH,102856,CDM,270,RC,,,,,Inpatient,,,155.8,,,,80,,124.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,121.06,percent of total billed charges,,,95,,148.01,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,148.01,
VERSAPORT TROCAR 11.5MM,102859,CDM,270,RC,,,,,Outpatient,,,36,,,,80,,28.8,percent of total billed charges,,,,85,30.6,percent of total billed charges,,,77.7,,27.97,percent of total billed charges,,,95,,34.2,percent of total billed charges,,,60,,21.6,percent of total billed charges,,21.6,34.2,
VERSAPORT TROCAR 11.5MM,102859,CDM,270,RC,,,,,Inpatient,,,36,,,,80,,28.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,27.97,percent of total billed charges,,,95,,34.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,34.2,
STAPLER LDS-15W,102861,CDM,270,RC,,,,,Outpatient,,,1172.1,,,,80,,937.68,percent of total billed charges,,,,85,996.29,percent of total billed charges,,,77.7,,910.72,percent of total billed charges,,,95,,1113.5,percent of total billed charges,,,60,,703.26,percent of total billed charges,,703.26,1113.5,
STAPLER LDS-15W,102861,CDM,270,RC,,,,,Inpatient,,,1172.1,,,,80,,937.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,910.72,percent of total billed charges,,,95,,1113.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1113.5,
SURGIWAND W/SPOON DISECTOR,102864,CDM,270,RC,,,,,Outpatient,,,682.5,,,,80,,546,percent of total billed charges,,,,85,580.13,percent of total billed charges,,,77.7,,530.3,percent of total billed charges,,,95,,648.38,percent of total billed charges,,,60,,409.5,percent of total billed charges,,409.5,648.38,
SURGIWAND W/SPOON DISECTOR,102864,CDM,270,RC,,,,,Inpatient,,,682.5,,,,80,,546,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,530.3,percent of total billed charges,,,95,,648.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,648.38,
C1781 PROLENE MESH 6X6,102868,CDM,278,RC,C1781,HCPCS,,,Outpatient,,,309.9,,,,80,,247.92,percent of total billed charges,,,,85,263.42,percent of total billed charges,,,77.7,,240.79,percent of total billed charges,,,95,,294.41,percent of total billed charges,,,60,,185.94,percent of total billed charges,,185.94,294.41,
C1781 PROLENE MESH 6X6,102868,CDM,278,RC,C1781,HCPCS,,,Inpatient,,,309.9,,,,80,,247.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,240.79,percent of total billed charges,,,95,,294.41,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,294.41,
C1781 PROLENE MESH 3X6,102869,CDM,278,RC,C1781,HCPCS,,,Outpatient,,,385.1,,,,80,,308.08,percent of total billed charges,,,,85,327.34,percent of total billed charges,,,77.7,,299.22,percent of total billed charges,,,95,,365.85,percent of total billed charges,,,60,,231.06,percent of total billed charges,,231.06,365.85,
C1781 PROLENE MESH 3X6,102869,CDM,278,RC,C1781,HCPCS,,,Inpatient,,,385.1,,,,80,,308.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,299.22,percent of total billed charges,,,95,,365.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,365.85,
TISUTRAP 8MM,102870,CDM,270,RC,,,,,Outpatient,,,50.4,,,,80,,40.32,percent of total billed charges,,,,85,42.84,percent of total billed charges,,,77.7,,39.16,percent of total billed charges,,,95,,47.88,percent of total billed charges,,,60,,30.24,percent of total billed charges,,30.24,47.88,
TISUTRAP 8MM,102870,CDM,270,RC,,,,,Inpatient,,,50.4,,,,80,,40.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,39.16,percent of total billed charges,,,95,,47.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,47.88,
TISUTRAP 10MM,102871,CDM,270,RC,,,,,Outpatient,,,50.4,,,,80,,40.32,percent of total billed charges,,,,85,42.84,percent of total billed charges,,,77.7,,39.16,percent of total billed charges,,,95,,47.88,percent of total billed charges,,,60,,30.24,percent of total billed charges,,30.24,47.88,
TISUTRAP 10MM,102871,CDM,270,RC,,,,,Inpatient,,,50.4,,,,80,,40.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,39.16,percent of total billed charges,,,95,,47.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,47.88,
UTERINE CURETTE 10MM,102872,CDM,270,RC,,,,,Outpatient,,,4.8,,,,80,,3.84,percent of total billed charges,,,,85,4.08,percent of total billed charges,,,77.7,,3.73,percent of total billed charges,,,95,,4.56,percent of total billed charges,,,60,,2.88,percent of total billed charges,,2.88,4.56,
UTERINE CURETTE 10MM,102872,CDM,270,RC,,,,,Inpatient,,,4.8,,,,80,,3.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.73,percent of total billed charges,,,95,,4.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.56,
THORACIC CATHETER 32 FR,102873,CDM,270,RC,,,,,Outpatient,,,13.4,,,,80,,10.72,percent of total billed charges,,,,85,11.39,percent of total billed charges,,,77.7,,10.41,percent of total billed charges,,,95,,12.73,percent of total billed charges,,,60,,8.04,percent of total billed charges,,8.04,12.73,
THORACIC CATHETER 32 FR,102873,CDM,270,RC,,,,,Inpatient,,,13.4,,,,80,,10.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.41,percent of total billed charges,,,95,,12.73,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,12.73,
STIRRUP STRAP,102874,CDM,270,RC,,,,,Outpatient,,,12.9,,,,80,,10.32,percent of total billed charges,,,,85,10.97,percent of total billed charges,,,77.7,,10.02,percent of total billed charges,,,95,,12.26,percent of total billed charges,,,60,,7.74,percent of total billed charges,,7.74,12.26,
STIRRUP STRAP,102874,CDM,270,RC,,,,,Inpatient,,,12.9,,,,80,,10.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.02,percent of total billed charges,,,95,,12.26,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,12.26,
"EXTENSION LINE 60""",102877,CDM,270,RC,,,,,Outpatient,,,140,,,,80,,112,percent of total billed charges,,,,85,119,percent of total billed charges,,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,60,,84,percent of total billed charges,,84,133,
"EXTENSION LINE 60""",102877,CDM,270,RC,,,,,Inpatient,,,140,,,,80,,112,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,133,
C1727PREPERITONEAL BALLOON,102879,CDM,278,RC,C1727,HCPCS,,,Outpatient,,,1224.7,,,,80,,979.76,percent of total billed charges,,,,85,1041,percent of total billed charges,,,77.7,,951.59,percent of total billed charges,,,95,,1163.47,percent of total billed charges,,,60,,734.82,percent of total billed charges,,734.82,1163.47,
C1727PREPERITONEAL BALLOON,102879,CDM,278,RC,C1727,HCPCS,,,Inpatient,,,1224.7,,,,80,,979.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,951.59,percent of total billed charges,,,95,,1163.47,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1163.47,
COMBO PAK CO2 LINE/VERESS NEEDLE,102881,CDM,270,RC,,,,,Outpatient,,,79.4,,,,80,,63.52,percent of total billed charges,,,,85,67.49,percent of total billed charges,,,77.7,,61.69,percent of total billed charges,,,95,,75.43,percent of total billed charges,,,60,,47.64,percent of total billed charges,,47.64,75.43,
COMBO PAK CO2 LINE/VERESS NEEDLE,102881,CDM,270,RC,,,,,Inpatient,,,79.4,,,,80,,63.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,61.69,percent of total billed charges,,,95,,75.43,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,75.43,
HUBER 20G 3/4IN,102882,CDM,270,RC,,,,,Outpatient,,,13.8,,,,80,,11.04,percent of total billed charges,,,,85,11.73,percent of total billed charges,,,77.7,,10.72,percent of total billed charges,,,95,,13.11,percent of total billed charges,,,60,,8.28,percent of total billed charges,,8.28,13.11,
HUBER 20G 3/4IN,102882,CDM,270,RC,,,,,Inpatient,,,13.8,,,,80,,11.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.72,percent of total billed charges,,,95,,13.11,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.11,
NEEDLE EPIDURAL 4 1/2X17G TUOHY,102884,CDM,270,RC,,,,,Outpatient,,,76.6,,,,80,,61.28,percent of total billed charges,,,,85,65.11,percent of total billed charges,,,77.7,,59.52,percent of total billed charges,,,95,,72.77,percent of total billed charges,,,60,,45.96,percent of total billed charges,,45.96,72.77,
NEEDLE EPIDURAL 4 1/2X17G TUOHY,102884,CDM,270,RC,,,,,Inpatient,,,76.6,,,,80,,61.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,59.52,percent of total billed charges,,,95,,72.77,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,72.77,
VERSAONE TROCAR 5MM X 100MM,102886,CDM,270,RC,,,,,Outpatient,,,38.9,,,,80,,31.12,percent of total billed charges,,,,85,33.07,percent of total billed charges,,,77.7,,30.23,percent of total billed charges,,,95,,36.96,percent of total billed charges,,,60,,23.34,percent of total billed charges,,23.34,36.96,
VERSAONE TROCAR 5MM X 100MM,102886,CDM,270,RC,,,,,Inpatient,,,38.9,,,,80,,31.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,30.23,percent of total billed charges,,,95,,36.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,36.96,
VERSAPORT TROCAR 5-11MM,102887,CDM,270,RC,,,,,Outpatient,,,399.6,,,,80,,319.68,percent of total billed charges,,,,85,339.66,percent of total billed charges,,,77.7,,310.49,percent of total billed charges,,,95,,379.62,percent of total billed charges,,,60,,239.76,percent of total billed charges,,239.76,379.62,
VERSAPORT TROCAR 5-11MM,102887,CDM,270,RC,,,,,Inpatient,,,399.6,,,,80,,319.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,310.49,percent of total billed charges,,,95,,379.62,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,379.62,
SODIUM CHLORIDE 0.9% IRRIGATION,102897,CDM,270,RC,,,,,Outpatient,,,11.5,,,,80,,9.2,percent of total billed charges,,,,85,9.78,percent of total billed charges,,,77.7,,8.94,percent of total billed charges,,,95,,10.93,percent of total billed charges,,,60,,6.9,percent of total billed charges,,6.9,10.93,
SODIUM CHLORIDE 0.9% IRRIGATION,102897,CDM,270,RC,,,,,Inpatient,,,11.5,,,,80,,9.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.94,percent of total billed charges,,,95,,10.93,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.93,
Jada Hemorrhage System,102921,CDM,270,RC,,,,,Outpatient,,,4532.5,,,,80,,3626,percent of total billed charges,,,,85,3852.63,percent of total billed charges,,,77.7,,3521.75,percent of total billed charges,,,95,,4305.88,percent of total billed charges,,,60,,2719.5,percent of total billed charges,,2719.5,4305.88,
Jada Hemorrhage System,102921,CDM,270,RC,,,,,Inpatient,,,4532.5,,,,80,,3626,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3521.75,percent of total billed charges,,,95,,4305.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4305.88,
"STRAIGHT CATHETER,14FRX16''",102933,CDM,270,RC,,,,,Outpatient,,,1.7,,,,80,,1.36,percent of total billed charges,,,,85,1.45,percent of total billed charges,,,77.7,,1.32,percent of total billed charges,,,95,,1.62,percent of total billed charges,,,60,,1.02,percent of total billed charges,,1.02,1.62,
"STRAIGHT CATHETER,14FRX16''",102933,CDM,270,RC,,,,,Inpatient,,,1.7,,,,80,,1.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.32,percent of total billed charges,,,95,,1.62,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.62,
US Bladder,400188,CDM,402,RC,51798,CPT,,,Outpatient,,,95,,,,80,,76,percent of total billed charges,,,,50,33.84,fee schedule,,,77.7,,73.82,percent of total billed charges,,,95,,90.25,percent of total billed charges,,,60,,57,percent of total billed charges,,57,90.25,
US Bladder,400188,CDM,402,RC,51798,CPT,,,Inpatient,,,95,,,,80,,76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,73.82,percent of total billed charges,,,95,,90.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,90.25,
O2 DAILY CHARGE,2730059,CDM,270,RC,,,,,Outpatient,,,258,,,,80,,206.4,percent of total billed charges,,,,85,219.3,percent of total billed charges,,,77.7,,200.47,percent of total billed charges,,,95,,245.1,percent of total billed charges,,,60,,154.8,percent of total billed charges,,154.8,245.1,
O2 DAILY CHARGE,2730059,CDM,270,RC,,,,,Inpatient,,,258,,,,80,,206.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,200.47,percent of total billed charges,,,95,,245.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,245.1,
Amylase Level,3000031,CDM,300,RC,82150,CPT,,,Outpatient,,,70,,,,80,,56,percent of total billed charges,,,,50,12.53,fee schedule,,,77.7,,54.39,percent of total billed charges,,,95,,66.5,percent of total billed charges,,,60,,42,percent of total billed charges,,42,66.5,
Amylase Level,3000031,CDM,300,RC,82150,CPT,,,Inpatient,,,70,,,,80,,56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,54.39,percent of total billed charges,,,95,,66.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,66.5,
Hemoglobin,3000122,CDM,300,RC,85018,CPT,,,Outpatient,,,30,,,,80,,24,percent of total billed charges,,,,50,4.88,fee schedule,,,77.7,,23.31,percent of total billed charges,,,95,,28.5,percent of total billed charges,,,60,,18,percent of total billed charges,,18,28.5,
Hemoglobin and Hematocrit,3000122,CDM,300,RC,85018,CPT,,,Outpatient,,,30,,,,80,,24,percent of total billed charges,,,,50,4.88,fee schedule,,,77.7,,23.31,percent of total billed charges,,,95,,28.5,percent of total billed charges,,,60,,18,percent of total billed charges,,18,28.5,
Hemoglobin,3000122,CDM,300,RC,85018,CPT,,,Inpatient,,,30,,,,80,,24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,23.31,percent of total billed charges,,,95,,28.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,28.5,
Hemoglobin and Hematocrit,3000122,CDM,300,RC,85018,CPT,,,Inpatient,,,30,,,,80,,24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,23.31,percent of total billed charges,,,95,,28.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,28.5,
Manual Differential (28),3000148,CDM,300,RC,85007,CPT,,,Outpatient,,,31,,,,80,,24.8,percent of total billed charges,,,,50,3.77,fee schedule,,,77.7,,24.09,percent of total billed charges,,,95,,29.45,percent of total billed charges,,,60,,18.6,percent of total billed charges,,18.6,29.45,
Manual Differential (28),3000148,CDM,300,RC,85007,CPT,,,Inpatient,,,31,,,,80,,24.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,24.09,percent of total billed charges,,,95,,29.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,29.45,
C-Reactive Protein,3000171,CDM,300,RC,86140,CPT,,,Outpatient,,,78,,,,80,,62.4,percent of total billed charges,,,,50,13.07,fee schedule,,,77.7,,60.61,percent of total billed charges,,,95,,74.1,percent of total billed charges,,,60,,46.8,percent of total billed charges,,46.8,74.1,
C-Reactive Protein,3000171,CDM,300,RC,86140,CPT,,,Inpatient,,,78,,,,80,,62.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,60.61,percent of total billed charges,,,95,,74.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,74.1,
Calcium Level Total,3000189,CDM,300,RC,82310,CPT,,,Outpatient,,,64,,,,80,,51.2,percent of total billed charges,,,,50,5.53,fee schedule,,,77.7,,49.73,percent of total billed charges,,,95,,60.8,percent of total billed charges,,,60,,38.4,percent of total billed charges,,38.4,60.8,
Calcium Level Total,3000189,CDM,300,RC,82310,CPT,,,Inpatient,,,64,,,,80,,51.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,49.73,percent of total billed charges,,,95,,60.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,60.8,
Carbon Dioxide Level,3000197,CDM,300,RC,82374,CPT,,,Outpatient,,,73,,,,80,,58.4,percent of total billed charges,,,,50,5.25,fee schedule,,,77.7,,56.72,percent of total billed charges,,,95,,69.35,percent of total billed charges,,,60,,43.8,percent of total billed charges,,43.8,69.35,
Carbon Dioxide Level,3000197,CDM,300,RC,82374,CPT,,,Inpatient,,,73,,,,80,,58.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,56.72,percent of total billed charges,,,95,,69.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,69.35,
Cholesterol,3000213,CDM,300,RC,82465,CPT,,,Outpatient,,,60,,,,80,,48,percent of total billed charges,,,,50,5.44,fee schedule,,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,60,,36,percent of total billed charges,,36,57,
Cholesterol,3000213,CDM,300,RC,82465,CPT,,,Inpatient,,,60,,,,80,,48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,57,
Creatine Kinase,3000254,CDM,300,RC,82550,CPT,,,Outpatient,,,60,,,,80,,48,percent of total billed charges,,,,50,11.56,fee schedule,,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,60,,36,percent of total billed charges,,36,57,
Creatine Kinase,3000254,CDM,300,RC,82550,CPT,,,Inpatient,,,60,,,,80,,48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,57,
Creatinine,3000262,CDM,300,RC,82565,CPT,,,Outpatient,,,60,,,,80,,48,percent of total billed charges,,,,50,5.5,fee schedule,,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,60,,36,percent of total billed charges,,36,57,
Creatinine,3000262,CDM,300,RC,82565,CPT,,,Inpatient,,,60,,,,80,,48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,57,
U Creatinine,3000288,CDM,300,RC,82575,CPT,,,Outpatient,,,73,,,,80,,58.4,percent of total billed charges,,,,50,17.56,fee schedule,,,77.7,,56.72,percent of total billed charges,,,95,,69.35,percent of total billed charges,,,60,,43.8,percent of total billed charges,,43.8,69.35,
U Creatinine,3000288,CDM,300,RC,82575,CPT,,,Inpatient,,,73,,,,80,,58.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,56.72,percent of total billed charges,,,95,,69.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,69.35,
"Copper, Serum LC",3000296,CDM,309,RC,82525,CPT,,,Outpatient,,,55,,,,80,,44,percent of total billed charges,,,,50,13.45,fee schedule,,,77.7,,42.74,percent of total billed charges,,,95,,52.25,percent of total billed charges,,,60,,33,percent of total billed charges,,33,52.25,
"Copper, Serum LC",3000296,CDM,309,RC,82525,CPT,,,Inpatient,,,55,,,,80,,44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,42.74,percent of total billed charges,,,95,,52.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,52.25,
Glucose Level,3000353,CDM,300,RC,82947,CPT,,,Outpatient,,,60,,,,80,,48,percent of total billed charges,,,,50,4.32,fee schedule,,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,60,,36,percent of total billed charges,,36,57,
Glucose Level,3000353,CDM,300,RC,82947,CPT,,,Inpatient,,,60,,,,80,,48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,57,
Gluc 1 Hr Post,3000361,CDM,300,RC,82950,CPT,,,Outpatient,,,57,,,,80,,45.6,percent of total billed charges,,,,50,10.04,fee schedule,,,77.7,,44.29,percent of total billed charges,,,95,,54.15,percent of total billed charges,,,60,,34.2,percent of total billed charges,,34.2,54.15,
Gluc 1 Hr Post,3000361,CDM,300,RC,82950,CPT,,,Inpatient,,,57,,,,80,,45.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,44.29,percent of total billed charges,,,95,,54.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,54.15,
85014 Hematocrit,3000387,CDM,300,RC,85014,CPT,,,Outpatient,,,25,,,,80,,20,percent of total billed charges,,,,50,4.46,fee schedule,,,77.7,,19.43,percent of total billed charges,,,95,,23.75,percent of total billed charges,,,60,,15,percent of total billed charges,,15,23.75,
Hematocrit,3000387,CDM,300,RC,85014,CPT,,,Outpatient,,,25,,,,80,,20,percent of total billed charges,,,,50,4.46,fee schedule,,,77.7,,19.43,percent of total billed charges,,,95,,23.75,percent of total billed charges,,,60,,15,percent of total billed charges,,15,23.75,
85014 Hematocrit,3000387,CDM,300,RC,85014,CPT,,,Inpatient,,,25,,,,80,,20,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.43,percent of total billed charges,,,95,,23.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,23.75,
Hematocrit,3000387,CDM,300,RC,85014,CPT,,,Inpatient,,,25,,,,80,,20,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.43,percent of total billed charges,,,95,,23.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,23.75,
Iron Level,3000403,CDM,300,RC,83540,CPT,,,Outpatient,,,75,,,,80,,60,percent of total billed charges,,,,50,12.81,fee schedule,,,77.7,,58.28,percent of total billed charges,,,95,,71.25,percent of total billed charges,,,60,,45,percent of total billed charges,,45,71.25,
Iron Level,3000403,CDM,300,RC,83540,CPT,,,Inpatient,,,75,,,,80,,60,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,58.28,percent of total billed charges,,,95,,71.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,71.25,
LDH,3000429,CDM,300,RC,83615,CPT,,,Outpatient,,,60,,,,80,,48,percent of total billed charges,,,,50,11.39,fee schedule,,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,60,,36,percent of total billed charges,,36,57,
LDH,3000429,CDM,300,RC,83615,CPT,,,Inpatient,,,60,,,,80,,48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,57,
Lipase Level,3000437,CDM,300,RC,83690,CPT,,,Outpatient,,,81,,,,80,,64.8,percent of total billed charges,,,,50,13.89,fee schedule,,,77.7,,62.94,percent of total billed charges,,,95,,76.95,percent of total billed charges,,,60,,48.6,percent of total billed charges,,48.6,76.95,
Lipase Level,3000437,CDM,300,RC,83690,CPT,,,Inpatient,,,81,,,,80,,64.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,62.94,percent of total billed charges,,,95,,76.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,76.95,
Magnesium Level,3000452,CDM,300,RC,83735,CPT,,,Outpatient,,,78,,,,80,,62.4,percent of total billed charges,,,,50,12.93,fee schedule,,,77.7,,60.61,percent of total billed charges,,,95,,74.1,percent of total billed charges,,,60,,46.8,percent of total billed charges,,46.8,74.1,
Magnesium Level,3000452,CDM,300,RC,83735,CPT,,,Inpatient,,,78,,,,80,,62.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,60.61,percent of total billed charges,,,95,,74.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,74.1,
Rapid Mono Screen with QC,3000460,CDM,309,RC,86308,CPT,,,Outpatient,,,62,,,,80,,49.6,percent of total billed charges,,,,50,9.75,fee schedule,,,77.7,,48.17,percent of total billed charges,,,95,,58.9,percent of total billed charges,,,60,,37.2,percent of total billed charges,,37.2,58.9,
Rapid Mono Screen with QC,3000460,CDM,309,RC,86308,CPT,,,Inpatient,,,62,,,,80,,49.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,48.17,percent of total billed charges,,,95,,58.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,58.9,
Phosphorus Level,3000502,CDM,300,RC,84100,CPT,,,Outpatient,,,60,,,,80,,48,percent of total billed charges,,,,50,5.09,fee schedule,,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,60,,36,percent of total billed charges,,36,57,
Phosphorus Level,3000502,CDM,300,RC,84100,CPT,,,Inpatient,,,60,,,,80,,48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,57,
Potassium Level,3000528,CDM,300,RC,84132,CPT,,,Outpatient,,,60,,,,80,,48,percent of total billed charges,,,,50,4.94,fee schedule,,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,60,,36,percent of total billed charges,,36,57,
Potassium Level,3000528,CDM,300,RC,84132,CPT,,,Inpatient,,,60,,,,80,,48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,57,
Protein Total,3000536,CDM,300,RC,84155,CPT,,,Outpatient,,,60,,,,80,,48,percent of total billed charges,,,,50,4.32,fee schedule,,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,60,,36,percent of total billed charges,,36,57,
Protein Total,3000536,CDM,300,RC,84155,CPT,,,Inpatient,,,60,,,,80,,48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,57,
PT,3000544,CDM,300,RC,85610,CPT,,,Outpatient,,,49,,,,80,,39.2,percent of total billed charges,,,,50,8.04,fee schedule,,,77.7,,38.07,percent of total billed charges,,,95,,46.55,percent of total billed charges,,,60,,29.4,percent of total billed charges,,29.4,46.55,
PT,3000544,CDM,300,RC,85610,CPT,,,Inpatient,,,49,,,,80,,39.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,38.07,percent of total billed charges,,,95,,46.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,46.55,
Partial Thromboplastin Time,3000551,CDM,300,RC,85730,CPT,,,Outpatient,,,67,,,,80,,53.6,percent of total billed charges,,,,50,11.27,fee schedule,,,77.7,,52.06,percent of total billed charges,,,95,,63.65,percent of total billed charges,,,60,,40.2,percent of total billed charges,,40.2,63.65,
Partial Thromboplastin Time,3000551,CDM,300,RC,85730,CPT,,,Inpatient,,,67,,,,80,,53.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,52.06,percent of total billed charges,,,95,,63.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,63.65,
Aspartate Aminotransferase,3000635,CDM,300,RC,84450,CPT,,,Outpatient,,,60,,,,80,,48,percent of total billed charges,,,,50,5.56,fee schedule,,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,60,,36,percent of total billed charges,,36,57,
Aspartate Aminotransferase,3000635,CDM,300,RC,84450,CPT,,,Inpatient,,,60,,,,80,,48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,57,
Alanine Aminotransferase,3000643,CDM,300,RC,84460,CPT,,,Outpatient,,,60,,,,80,,48,percent of total billed charges,,,,50,5.68,fee schedule,,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,60,,36,percent of total billed charges,,36,57,
Alanine Aminotransferase,3000643,CDM,300,RC,84460,CPT,,,Inpatient,,,60,,,,80,,48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,57,
Blood Urea Nitrogen,3000650,CDM,300,RC,84520,CPT,,,Outpatient,,,60,,,,80,,48,percent of total billed charges,,,,50,4.24,fee schedule,,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,60,,36,percent of total billed charges,,36,57,
Blood Urea Nitrogen,3000650,CDM,300,RC,84520,CPT,,,Inpatient,,,60,,,,80,,48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,57,
Uric Acid,3000668,CDM,300,RC,84550,CPT,,,Outpatient,,,44,,,,80,,35.2,percent of total billed charges,,,,50,7.36,fee schedule,,,77.7,,34.19,percent of total billed charges,,,95,,41.8,percent of total billed charges,,,60,,26.4,percent of total billed charges,,26.4,41.8,
Uric Acid,3000668,CDM,300,RC,84550,CPT,,,Inpatient,,,44,,,,80,,35.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,34.19,percent of total billed charges,,,95,,41.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,41.8,
Triiodothyronine (T3) LC,3000676,CDM,309,RC,84480,CPT,,,Outpatient,,,122,,,,80,,97.6,percent of total billed charges,,,,50,23.6,fee schedule,,,77.7,,94.79,percent of total billed charges,,,95,,115.9,percent of total billed charges,,,60,,73.2,percent of total billed charges,,73.2,115.9,
Triiodothyronine (T3) LC,3000676,CDM,309,RC,84480,CPT,,,Inpatient,,,122,,,,80,,97.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,94.79,percent of total billed charges,,,95,,115.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,115.9,
ABORh GL,3000726,CDM,300,RC,86900,CPT,,,Outpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,50,105.38,fee schedule,,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,60,,157.06,percent of total billed charges,,157.06,248.68,
ABORh GL,3000726,CDM,300,RC,86900,CPT,,,Inpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,248.68,
Rapid Occult Blood Screen Stool,3000767,CDM,300,RC,82270,CPT,,,Outpatient,,,36,,,,80,,28.8,percent of total billed charges,,,,50,6.21,fee schedule,,,77.7,,27.97,percent of total billed charges,,,95,,34.2,percent of total billed charges,,,60,,21.6,percent of total billed charges,,21.6,34.2,
Rapid Occult Blood Screen Stool,3000767,CDM,300,RC,82270,CPT,,,Inpatient,,,36,,,,80,,28.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,27.97,percent of total billed charges,,,95,,34.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,34.2,
"Rapid Plasma Reagin, Quant LC",3000916,CDM,309,RC,86593,CPT,,,Outpatient,,,63,,,,80,,50.4,percent of total billed charges,,,,50,11.28,fee schedule,,,77.7,,48.95,percent of total billed charges,,,95,,59.85,percent of total billed charges,,,60,,37.8,percent of total billed charges,,37.8,59.85,
"Rapid Plasma Reagin, Quant LC",3000916,CDM,309,RC,86593,CPT,,,Inpatient,,,63,,,,80,,50.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,48.95,percent of total billed charges,,,95,,59.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,59.85,
Rapid Pregnancy Test Urine,3001039,CDM,300,RC,81025,CPT,,,Outpatient,,,40,,,,80,,32,percent of total billed charges,,,,50,13.57,fee schedule,,,77.7,,31.08,percent of total billed charges,,,95,,38,percent of total billed charges,,,60,,24,percent of total billed charges,,24,38,
Rapid Pregnancy Test Urine,3001039,CDM,300,RC,81025,CPT,,,Inpatient,,,40,,,,80,,32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,31.08,percent of total billed charges,,,95,,38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,38,
Aldosterone/Renin Ratio - LC,3001047,CDM,309,RC,82088,CPT,,,Outpatient,,,302,,,,80,,241.6,percent of total billed charges,,,,50,61.6,fee schedule,,,77.7,,234.65,percent of total billed charges,,,95,,286.9,percent of total billed charges,,,60,,181.2,percent of total billed charges,,181.2,286.9,
Aldosterone/Renin Ratio - LC,3001047,CDM,309,RC,82088,CPT,,,Inpatient,,,302,,,,80,,241.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,234.65,percent of total billed charges,,,95,,286.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,286.9,
FSH and LH LC,3001120,CDM,309,RC,83001,CPT,,,Outpatient,,,194,,,,80,,155.2,percent of total billed charges,,,,50,35.65,fee schedule,,,77.7,,150.74,percent of total billed charges,,,95,,184.3,percent of total billed charges,,,60,,116.4,percent of total billed charges,,116.4,184.3,
"FSH, Serum LC",3001120,CDM,309,RC,83001,CPT,,,Outpatient,,,194,,,,80,,155.2,percent of total billed charges,,,,50,35.65,fee schedule,,,77.7,,150.74,percent of total billed charges,,,95,,184.3,percent of total billed charges,,,60,,116.4,percent of total billed charges,,116.4,184.3,
FSH and LH LC,3001120,CDM,309,RC,83001,CPT,,,Inpatient,,,194,,,,80,,155.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,150.74,percent of total billed charges,,,95,,184.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,184.3,
"FSH, Serum LC",3001120,CDM,309,RC,83001,CPT,,,Inpatient,,,194,,,,80,,155.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,150.74,percent of total billed charges,,,95,,184.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,184.3,
"Luteinizing Hormone(LH), S LC",3001203,CDM,309,RC,83002,CPT,,,Outpatient,,,181,,,,80,,144.8,percent of total billed charges,,,,50,34.78,fee schedule,,,77.7,,140.64,percent of total billed charges,,,95,,171.95,percent of total billed charges,,,60,,108.6,percent of total billed charges,,108.6,171.95,
"Luteinizing Hormone(LH), S LC",3001203,CDM,309,RC,83002,CPT,,,Inpatient,,,181,,,,80,,144.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,140.64,percent of total billed charges,,,95,,171.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,171.95,
Triglycerides,3001369,CDM,300,RC,84478,CPT,,,Outpatient,,,50,,,,80,,40,percent of total billed charges,,,,50,6.18,fee schedule,,,77.7,,38.85,percent of total billed charges,,,95,,47.5,percent of total billed charges,,,60,,30,percent of total billed charges,,30,47.5,
Triglycerides,3001369,CDM,300,RC,84478,CPT,,,Inpatient,,,50,,,,80,,40,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,38.85,percent of total billed charges,,,95,,47.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,47.5,
Hgb A1c,3001385,CDM,300,RC,83036,CPT,,,Outpatient,,,97,,,,80,,77.6,percent of total billed charges,,,,50,17.97,fee schedule,,,77.7,,75.37,percent of total billed charges,,,95,,92.15,percent of total billed charges,,,60,,58.2,percent of total billed charges,,58.2,92.15,
Hgb A1c,3001385,CDM,300,RC,83036,CPT,,,Inpatient,,,97,,,,80,,77.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,75.37,percent of total billed charges,,,95,,92.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,92.15,
"Folate (Folic Acid), Serum LC",3001591,CDM,309,RC,82746,CPT,,,Outpatient,,,169,,,,80,,135.2,percent of total billed charges,,,,50,30.91,fee schedule,,,77.7,,131.31,percent of total billed charges,,,95,,160.55,percent of total billed charges,,,60,,101.4,percent of total billed charges,,101.4,160.55,
"Folate (Folic Acid), Serum LC",3001591,CDM,309,RC,82746,CPT,,,Inpatient,,,169,,,,80,,135.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,131.31,percent of total billed charges,,,95,,160.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,160.55,
"AFP, Serum, Tumor Marker LC",3001609,CDM,309,RC,82105,CPT,,,Outpatient,,,158,,,,80,,126.4,percent of total billed charges,,,,50,27.82,fee schedule,,,77.7,,122.77,percent of total billed charges,,,95,,150.1,percent of total billed charges,,,60,,94.8,percent of total billed charges,,94.8,150.1,
"AFP, Serum, Tumor Marker LC",3001609,CDM,309,RC,82105,CPT,,,Inpatient,,,158,,,,80,,126.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,122.77,percent of total billed charges,,,95,,150.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,150.1,
Vitamin B12 LC,3001666,CDM,309,RC,82607,CPT,,,Outpatient,,,150,,,,80,,120,percent of total billed charges,,,,50,28.71,fee schedule,,,77.7,,116.55,percent of total billed charges,,,95,,142.5,percent of total billed charges,,,60,,90,percent of total billed charges,,90,142.5,
Vitamin B12 LC,3001666,CDM,309,RC,82607,CPT,,,Inpatient,,,150,,,,80,,120,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,116.55,percent of total billed charges,,,95,,142.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,142.5,
"Immunoglobulin E, Total LC",3001708,CDM,309,RC,82785,CPT,,,Outpatient,,,168,,,,80,,134.4,percent of total billed charges,,,,50,31.64,fee schedule,,,77.7,,130.54,percent of total billed charges,,,95,,159.6,percent of total billed charges,,,60,,100.8,percent of total billed charges,,100.8,159.6,
"Immunoglobulin E, Total LC",3001708,CDM,309,RC,82785,CPT,,,Inpatient,,,168,,,,80,,134.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,130.54,percent of total billed charges,,,95,,159.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,159.6,
CK-MB,3001815,CDM,300,RC,82553,CPT,,,Outpatient,,,160,,,,80,,128,percent of total billed charges,,,,50,27.01,fee schedule,,,77.7,,124.32,percent of total billed charges,,,95,,152,percent of total billed charges,,,60,,96,percent of total billed charges,,96,152,
CK-MB,3001815,CDM,300,RC,82553,CPT,,,Inpatient,,,160,,,,80,,128,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,124.32,percent of total billed charges,,,95,,152,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,152,
"ACTH, Plasma LC",3001856,CDM,309,RC,82024,CPT,,,Outpatient,,,147,,,,80,,117.6,percent of total billed charges,,,,50,59.19,fee schedule,,,77.7,,114.22,percent of total billed charges,,,95,,139.65,percent of total billed charges,,,60,,88.2,percent of total billed charges,,88.2,139.65,
"ACTH, Plasma LC",3001856,CDM,309,RC,82024,CPT,,,Inpatient,,,147,,,,80,,117.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,114.22,percent of total billed charges,,,95,,139.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,139.65,
Thyroid Stimulating Hormone,3001906,CDM,300,RC,84443,CPT,,,Outpatient,,,145,,,,80,,116,percent of total billed charges,,,,50,21.99,fee schedule,,,77.7,,112.67,percent of total billed charges,,,95,,137.75,percent of total billed charges,,,60,,87,percent of total billed charges,,87,137.75,
Thyroid Stimulating Hormone,3001906,CDM,300,RC,84443,CPT,,,Inpatient,,,145,,,,80,,116,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,112.67,percent of total billed charges,,,95,,137.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,137.75,
HDL,3001914,CDM,300,RC,83718,CPT,,,Outpatient,,,70,,,,80,,56,percent of total billed charges,,,,50,8.79,fee schedule,,,77.7,,54.39,percent of total billed charges,,,95,,66.5,percent of total billed charges,,,60,,42,percent of total billed charges,,42,66.5,
HDL,3001914,CDM,300,RC,83718,CPT,,,Inpatient,,,70,,,,80,,56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,54.39,percent of total billed charges,,,95,,66.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,66.5,
Blood Culture,3002086,CDM,300,RC,87040,CPT,,,Outpatient,,,112,,,,80,,89.6,percent of total billed charges,,,,50,19.21,fee schedule,,,77.7,,87.02,percent of total billed charges,,,95,,106.4,percent of total billed charges,,,60,,67.2,percent of total billed charges,,67.2,106.4,
Blood Culture,3002086,CDM,300,RC,87040,CPT,,,Inpatient,,,112,,,,80,,89.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,87.02,percent of total billed charges,,,95,,106.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,106.4,
Blood Gas Arterial,3002128,CDM,300,RC,82803,CPT,,,Outpatient,,,223,,,,80,,178.4,percent of total billed charges,,,,50,34.03,fee schedule,,,77.7,,173.27,percent of total billed charges,,,95,,211.85,percent of total billed charges,,,60,,133.8,percent of total billed charges,,133.8,211.85,
Blood Gas Arterial - Cord Blood,3002128,CDM,300,RC,82803,CPT,,,Outpatient,,,223,,,,80,,178.4,percent of total billed charges,,,,50,34.03,fee schedule,,,77.7,,173.27,percent of total billed charges,,,95,,211.85,percent of total billed charges,,,60,,133.8,percent of total billed charges,,133.8,211.85,
Blood Gas Arterial 1,3002128,CDM,300,RC,82803,CPT,,,Outpatient,,,223,,,,80,,178.4,percent of total billed charges,,,,50,34.03,fee schedule,,,77.7,,173.27,percent of total billed charges,,,95,,211.85,percent of total billed charges,,,60,,133.8,percent of total billed charges,,133.8,211.85,
Blood Gas Arterial 2,3002128,CDM,300,RC,82803,CPT,,,Outpatient,,,223,,,,80,,178.4,percent of total billed charges,,,,50,34.03,fee schedule,,,77.7,,173.27,percent of total billed charges,,,95,,211.85,percent of total billed charges,,,60,,133.8,percent of total billed charges,,133.8,211.85,
Blood Gas Arterial,3002128,CDM,300,RC,82803,CPT,,,Inpatient,,,223,,,,80,,178.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,173.27,percent of total billed charges,,,95,,211.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,211.85,
Blood Gas Arterial - Cord Blood,3002128,CDM,300,RC,82803,CPT,,,Inpatient,,,223,,,,80,,178.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,173.27,percent of total billed charges,,,95,,211.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,211.85,
Blood Gas Arterial 1,3002128,CDM,300,RC,82803,CPT,,,Inpatient,,,223,,,,80,,178.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,173.27,percent of total billed charges,,,95,,211.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,211.85,
Blood Gas Arterial 2,3002128,CDM,300,RC,82803,CPT,,,Inpatient,,,223,,,,80,,178.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,173.27,percent of total billed charges,,,95,,211.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,211.85,
Cortisol - AM - LC,3002409,CDM,309,RC,82533,CPT,,,Outpatient,,,167,,,,80,,133.6,percent of total billed charges,,,,50,30.27,fee schedule,,,77.7,,129.76,percent of total billed charges,,,95,,158.65,percent of total billed charges,,,60,,100.2,percent of total billed charges,,100.2,158.65,
Cortisol - PM - LC,3002409,CDM,309,RC,82533,CPT,,,Outpatient,,,167,,,,80,,133.6,percent of total billed charges,,,,50,30.27,fee schedule,,,77.7,,129.76,percent of total billed charges,,,95,,158.65,percent of total billed charges,,,60,,100.2,percent of total billed charges,,100.2,158.65,
Cortisol - AM - LC,3002409,CDM,309,RC,82533,CPT,,,Inpatient,,,167,,,,80,,133.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,129.76,percent of total billed charges,,,95,,158.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,158.65,
Cortisol - PM - LC,3002409,CDM,309,RC,82533,CPT,,,Inpatient,,,167,,,,80,,133.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,129.76,percent of total billed charges,,,95,,158.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,158.65,
Anaerobic Culture LC,3002417,CDM,309,RC,87075,CPT,,,Outpatient,,,85,,,,80,,68,percent of total billed charges,,,,50,15.61,fee schedule,,,77.7,,66.05,percent of total billed charges,,,95,,80.75,percent of total billed charges,,,60,,51,percent of total billed charges,,51,80.75,
Anaerobic Culture LC,3002417,CDM,309,RC,87075,CPT,,,Inpatient,,,85,,,,80,,68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,66.05,percent of total billed charges,,,95,,80.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,80.75,
Blood Culture - LC,3002532,CDM,309,RC,87040,CPT,,,Outpatient,,,112,,,,80,,89.6,percent of total billed charges,,,,50,19.21,fee schedule,,,77.7,,87.02,percent of total billed charges,,,95,,106.4,percent of total billed charges,,,60,,67.2,percent of total billed charges,,67.2,106.4,
Blood Culture - LC,3002532,CDM,309,RC,87040,CPT,,,Inpatient,,,112,,,,80,,89.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,87.02,percent of total billed charges,,,95,,106.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,106.4,
"Hep A Ab, Total LC",3002573,CDM,309,RC,86708,CPT,,,Outpatient,,,129,,,,80,,103.2,percent of total billed charges,,,,50,22.97,fee schedule,,,77.7,,100.23,percent of total billed charges,,,95,,122.55,percent of total billed charges,,,60,,77.4,percent of total billed charges,,77.4,122.55,
"Hep A Ab, Total LC",3002573,CDM,309,RC,86708,CPT,,,Inpatient,,,129,,,,80,,103.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,100.23,percent of total billed charges,,,95,,122.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,122.55,
HBsAb Screen LC,3002615,CDM,309,RC,86706,CPT,,,Outpatient,,,135,,,,80,,108,percent of total billed charges,,,,50,23.18,fee schedule,,,77.7,,104.9,percent of total billed charges,,,95,,128.25,percent of total billed charges,,,60,,81,percent of total billed charges,,81,128.25,
HBsAb Screen LC,3002615,CDM,309,RC,86706,CPT,,,Inpatient,,,135,,,,80,,108,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,104.9,percent of total billed charges,,,95,,128.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,128.25,
"Testosterone, Free, Direct LC",3002698,CDM,309,RC,84402,CPT,,,Outpatient,,,295,,,,80,,236,percent of total billed charges,,,,50,54.33,fee schedule,,,77.7,,229.22,percent of total billed charges,,,95,,280.25,percent of total billed charges,,,60,,177,percent of total billed charges,,177,280.25,
"Testosterone, Free, Direct LC",3002698,CDM,309,RC,84402,CPT,,,Inpatient,,,295,,,,80,,236,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,229.22,percent of total billed charges,,,95,,280.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,280.25,
"Testosterone, Total, LC/MS LC",3002706,CDM,309,RC,84403,CPT,,,Outpatient,,,284,,,,80,,227.2,percent of total billed charges,,,,50,52.43,fee schedule,,,77.7,,220.67,percent of total billed charges,,,95,,269.8,percent of total billed charges,,,60,,170.4,percent of total billed charges,,170.4,269.8,
"Testosterone, Total, LC/MS LC",3002706,CDM,309,RC,84403,CPT,,,Inpatient,,,284,,,,80,,227.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,220.67,percent of total billed charges,,,95,,269.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,269.8,
BhCG Quant,3002813,CDM,300,RC,84702,CPT,,,Outpatient,,,170,,,,80,,136,percent of total billed charges,,,,50,30.18,fee schedule,,,77.7,,132.09,percent of total billed charges,,,95,,161.5,percent of total billed charges,,,60,,102,percent of total billed charges,,102,161.5,
BhCG Quant,3002813,CDM,300,RC,84702,CPT,,,Inpatient,,,170,,,,80,,136,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,132.09,percent of total billed charges,,,95,,161.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,161.5,
Thyroxine Free,3002821,CDM,300,RC,84439,CPT,,,Outpatient,,,83,,,,80,,66.4,percent of total billed charges,,,,50,15.39,fee schedule,,,77.7,,64.49,percent of total billed charges,,,95,,78.85,percent of total billed charges,,,60,,49.8,percent of total billed charges,,49.8,78.85,
Thyroxine Free,3002821,CDM,300,RC,84439,CPT,,,Inpatient,,,83,,,,80,,66.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,64.49,percent of total billed charges,,,95,,78.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,78.85,
Gram Stain LC,3002896,CDM,309,RC,87205,CPT,,,Outpatient,,,45,,,,80,,36,percent of total billed charges,,,,50,7.27,fee schedule,,,77.7,,34.97,percent of total billed charges,,,95,,42.75,percent of total billed charges,,,60,,27,percent of total billed charges,,27,42.75,
Gram Stain LC,3002896,CDM,309,RC,87205,CPT,,,Inpatient,,,45,,,,80,,36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,34.97,percent of total billed charges,,,95,,42.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,42.75,
Sedimentation Rate,3002961,CDM,300,RC,85652,CPT,,,Outpatient,,,47,,,,80,,37.6,percent of total billed charges,,,,50,6.41,fee schedule,,,77.7,,36.52,percent of total billed charges,,,95,,44.65,percent of total billed charges,,,60,,28.2,percent of total billed charges,,28.2,44.65,
Sedimentation Rate,3002961,CDM,300,RC,85652,CPT,,,Inpatient,,,47,,,,80,,37.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,36.52,percent of total billed charges,,,95,,44.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,44.65,
HBsAg Screen LC,3003043,CDM,309,RC,87340,CPT,,,Outpatient,,,114,,,,80,,91.2,percent of total billed charges,,,,50,12.31,fee schedule,,,77.7,,88.58,percent of total billed charges,,,95,,108.3,percent of total billed charges,,,60,,68.4,percent of total billed charges,,68.4,108.3,
HBsAg Screen LC,3003043,CDM,309,RC,87340,CPT,,,Inpatient,,,114,,,,80,,91.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,88.58,percent of total billed charges,,,95,,108.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,108.3,
Aerobic Bacterial Culture LC,3003175,CDM,309,RC,87070,CPT,,,Outpatient,,,85,,,,80,,68,percent of total billed charges,,,,50,15.94,fee schedule,,,77.7,,66.05,percent of total billed charges,,,95,,80.75,percent of total billed charges,,,60,,51,percent of total billed charges,,51,80.75,
"Body Fluid Culture, Sterile LC",3003175,CDM,309,RC,87070,CPT,,,Outpatient,,,85,,,,80,,68,percent of total billed charges,,,,50,15.94,fee schedule,,,77.7,,66.05,percent of total billed charges,,,95,,80.75,percent of total billed charges,,,60,,51,percent of total billed charges,,51,80.75,
"Genital Culture, Routine LC",3003175,CDM,309,RC,87070,CPT,,,Outpatient,,,85,,,,80,,68,percent of total billed charges,,,,50,15.94,fee schedule,,,77.7,,66.05,percent of total billed charges,,,95,,80.75,percent of total billed charges,,,60,,51,percent of total billed charges,,51,80.75,
Upper Respiratory Culture LC,3003175,CDM,309,RC,87070,CPT,,,Outpatient,,,85,,,,80,,68,percent of total billed charges,,,,50,15.94,fee schedule,,,77.7,,66.05,percent of total billed charges,,,95,,80.75,percent of total billed charges,,,60,,51,percent of total billed charges,,51,80.75,
Aerobic Bacterial Culture LC,3003175,CDM,309,RC,87070,CPT,,,Inpatient,,,85,,,,80,,68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,66.05,percent of total billed charges,,,95,,80.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,80.75,
"Body Fluid Culture, Sterile LC",3003175,CDM,309,RC,87070,CPT,,,Inpatient,,,85,,,,80,,68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,66.05,percent of total billed charges,,,95,,80.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,80.75,
"Genital Culture, Routine LC",3003175,CDM,309,RC,87070,CPT,,,Inpatient,,,85,,,,80,,68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,66.05,percent of total billed charges,,,95,,80.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,80.75,
Upper Respiratory Culture LC,3003175,CDM,309,RC,87070,CPT,,,Inpatient,,,85,,,,80,,68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,66.05,percent of total billed charges,,,95,,80.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,80.75,
Progesterone LC,3003217,CDM,309,RC,84144,CPT,,,Outpatient,,,184,,,,80,,147.2,percent of total billed charges,,,,50,35.86,fee schedule,,,77.7,,142.97,percent of total billed charges,,,95,,174.8,percent of total billed charges,,,60,,110.4,percent of total billed charges,,110.4,174.8,
Progesterone LC,3003217,CDM,309,RC,84144,CPT,,,Inpatient,,,184,,,,80,,147.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,142.97,percent of total billed charges,,,95,,174.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,174.8,
"Metanephrines, Frac, Qn, 24-Hr LC",3003324,CDM,309,RC,83835,CPT,,,Outpatient,,,343,,,,80,,274.4,percent of total billed charges,,,,50,32.89,fee schedule,,,77.7,,266.51,percent of total billed charges,,,95,,325.85,percent of total billed charges,,,60,,205.8,percent of total billed charges,,205.8,325.85,
"Metanephrines, Frac, Qn, 24-Hr LC",3003324,CDM,309,RC,83835,CPT,,,Inpatient,,,343,,,,80,,274.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,266.51,percent of total billed charges,,,95,,325.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,325.85,
"Calcitriol(1,25 di-OH Vit D) LC",3003423,CDM,309,RC,82652,CPT,,,Outpatient,,,247,,,,80,,197.6,percent of total billed charges,,,,50,44.23,fee schedule,,,77.7,,191.92,percent of total billed charges,,,95,,234.65,percent of total billed charges,,,60,,148.2,percent of total billed charges,,148.2,234.65,
"Calcitriol(1,25 di-OH Vit D) LC",3003423,CDM,309,RC,82652,CPT,,,Inpatient,,,247,,,,80,,197.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,191.92,percent of total billed charges,,,95,,234.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,234.65,
"Calcium, Ionized, Serum LC",3003456,CDM,309,RC,82330,CPT,,,Outpatient,,,121,,,,80,,96.8,percent of total billed charges,,,,50,23.23,fee schedule,,,77.7,,94.02,percent of total billed charges,,,95,,114.95,percent of total billed charges,,,60,,72.6,percent of total billed charges,,72.6,114.95,
"Calcium, Ionized, Serum LC",3003456,CDM,309,RC,82330,CPT,,,Inpatient,,,121,,,,80,,96.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,94.02,percent of total billed charges,,,95,,114.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,114.95,
"PTH, Intact LC",3003464,CDM,309,RC,83970,CPT,,,Outpatient,,,416,,,,80,,332.8,percent of total billed charges,,,,50,77.51,fee schedule,,,77.7,,323.23,percent of total billed charges,,,95,,395.2,percent of total billed charges,,,60,,249.6,percent of total billed charges,,249.6,395.2,
"PTH, Intact LC",3003464,CDM,309,RC,83970,CPT,,,Inpatient,,,416,,,,80,,332.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,323.23,percent of total billed charges,,,95,,395.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,395.2,
"Cytomegalovirus (CMV) Ab, IgM LC",3003621,CDM,309,RC,86645,CPT,,,Outpatient,,,195,,,,80,,156,percent of total billed charges,,,,50,36.06,fee schedule,,,77.7,,151.52,percent of total billed charges,,,95,,185.25,percent of total billed charges,,,60,,117,percent of total billed charges,,117,185.25,
"Cytomegalovirus (CMV) Ab, IgM LC",3003621,CDM,309,RC,86645,CPT,,,Inpatient,,,195,,,,80,,156,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,151.52,percent of total billed charges,,,95,,185.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,185.25,
"EBV Nuclear Antigen Ab, IgG LC",3003639,CDM,309,RC,86664,CPT,,,Outpatient,,,231,,,,80,,184.8,percent of total billed charges,,,,50,31.3,fee schedule,,,77.7,,179.49,percent of total billed charges,,,95,,219.45,percent of total billed charges,,,60,,138.6,percent of total billed charges,,138.6,219.45,
"EBV Nuclear Antigen Ab, IgG LC",3003639,CDM,309,RC,86664,CPT,,,Inpatient,,,231,,,,80,,184.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,179.49,percent of total billed charges,,,95,,219.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,219.45,
EBV Acute Infection Antibodies LC,3003647,CDM,309,RC,86664,CPT,,,Outpatient,,,222,,,,80,,177.6,percent of total billed charges,,,,50,31.3,fee schedule,,,77.7,,172.49,percent of total billed charges,,,95,,210.9,percent of total billed charges,,,60,,133.2,percent of total billed charges,,133.2,210.9,
EBV Acute Infection Antibodies LC,3003647,CDM,309,RC,86664,CPT,,,Inpatient,,,222,,,,80,,177.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,172.49,percent of total billed charges,,,95,,210.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,210.9,
Rapid Pregnancy Test with QC,3003753,CDM,300,RC,84703,CPT,,,Outpatient,,,90,,,,80,,72,percent of total billed charges,,,,50,17.16,fee schedule,,,77.7,,69.93,percent of total billed charges,,,95,,85.5,percent of total billed charges,,,60,,54,percent of total billed charges,,54,85.5,
Rapid Pregnancy Test with QC,3003753,CDM,300,RC,84703,CPT,,,Inpatient,,,90,,,,80,,72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,69.93,percent of total billed charges,,,95,,85.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,85.5,
Ammonia Level,3003803,CDM,300,RC,82140,CPT,,,Outpatient,,,130,,,,80,,104,percent of total billed charges,,,,50,24.69,fee schedule,,,77.7,,101.01,percent of total billed charges,,,95,,123.5,percent of total billed charges,,,60,,78,percent of total billed charges,,78,123.5,
Ammonia Level,3003803,CDM,300,RC,82140,CPT,,,Inpatient,,,130,,,,80,,104,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,101.01,percent of total billed charges,,,95,,123.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,123.5,
Prolactin LC,3003811,CDM,309,RC,84146,CPT,,,Outpatient,,,216,,,,80,,172.8,percent of total billed charges,,,,50,39.71,fee schedule,,,77.7,,167.83,percent of total billed charges,,,95,,205.2,percent of total billed charges,,,60,,129.6,percent of total billed charges,,129.6,205.2,
Prolactin LC,3003811,CDM,309,RC,84146,CPT,,,Inpatient,,,216,,,,80,,172.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,167.83,percent of total billed charges,,,95,,205.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,205.2,
"Vitamin D, 25-Hydroxy LC",3003944,CDM,309,RC,82306,CPT,,,Outpatient,,,371,,,,80,,296.8,percent of total billed charges,,,,50,109.22,fee schedule,,,77.7,,288.27,percent of total billed charges,,,95,,352.45,percent of total billed charges,,,60,,222.6,percent of total billed charges,,222.6,352.45,
"Vitamin D, 25-Hydroxy LC",3003944,CDM,309,RC,82306,CPT,,,Inpatient,,,371,,,,80,,296.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,288.27,percent of total billed charges,,,95,,352.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,352.45,
Estradiol LC,3003951,CDM,309,RC,82670,CPT,,,Outpatient,,,335,,,,80,,268,percent of total billed charges,,,,50,62.6,fee schedule,,,77.7,,260.3,percent of total billed charges,,,95,,318.25,percent of total billed charges,,,60,,201,percent of total billed charges,,201,318.25,
Estradiol LC,3003951,CDM,309,RC,82670,CPT,,,Inpatient,,,335,,,,80,,268,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,260.3,percent of total billed charges,,,95,,318.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,318.25,
Phenobarbital - LC,3004215,CDM,309,RC,80184,CPT,,,Outpatient,,,142,,,,80,,113.6,percent of total billed charges,,,,50,27,fee schedule,,,77.7,,110.33,percent of total billed charges,,,95,,134.9,percent of total billed charges,,,60,,85.2,percent of total billed charges,,85.2,134.9,
Phenobarbital - LC,3004215,CDM,309,RC,80184,CPT,,,Inpatient,,,142,,,,80,,113.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,110.33,percent of total billed charges,,,95,,134.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,134.9,
"Hep B Core Ab, Tot LC",3004496,CDM,309,RC,86704,CPT,,,Outpatient,,,116,,,,80,,92.8,percent of total billed charges,,,,50,22.12,fee schedule,,,77.7,,90.13,percent of total billed charges,,,95,,110.2,percent of total billed charges,,,60,,69.6,percent of total billed charges,,69.6,110.2,
"Hep B Core Ab, Tot LC",3004496,CDM,309,RC,86704,CPT,,,Inpatient,,,116,,,,80,,92.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,90.13,percent of total billed charges,,,95,,110.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,110.2,
Wet Prep 1,3004595,CDM,300,RC,87210,CPT,,,Outpatient,,,45,,,,80,,36,percent of total billed charges,,,,50,8.19,fee schedule,,,77.7,,34.97,percent of total billed charges,,,95,,42.75,percent of total billed charges,,,60,,27,percent of total billed charges,,27,42.75,
Wet Prep 1,3004595,CDM,300,RC,87210,CPT,,,Inpatient,,,45,,,,80,,36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,34.97,percent of total billed charges,,,95,,42.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,42.75,
Insulin LC,3004678,CDM,309,RC,83525,CPT,,,Outpatient,,,240,,,,80,,192,percent of total billed charges,,,,50,25.36,fee schedule,,,77.7,,186.48,percent of total billed charges,,,95,,228,percent of total billed charges,,,60,,144,percent of total billed charges,,144,228,
Insulin LC,3004678,CDM,309,RC,83525,CPT,,,Inpatient,,,240,,,,80,,192,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,186.48,percent of total billed charges,,,95,,228,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,228,
Prostate Specific Antigen Diagnostic,3004769,CDM,300,RC,84153,CPT,,,Outpatient,,,178,,,,80,,142.4,percent of total billed charges,,,,50,33.98,fee schedule,,,77.7,,138.31,percent of total billed charges,,,95,,169.1,percent of total billed charges,,,60,,106.8,percent of total billed charges,,106.8,169.1,
Prostate Specific Antigen Diagnostic,3004769,CDM,300,RC,84153,CPT,,,Inpatient,,,178,,,,80,,142.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,138.31,percent of total billed charges,,,95,,169.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,169.1,
Troponin-I,3004777,CDM,300,RC,84484,CPT,,,Outpatient,,,185,,,,80,,148,percent of total billed charges,,,,50,34.3,fee schedule,,,77.7,,143.75,percent of total billed charges,,,95,,175.75,percent of total billed charges,,,60,,111,percent of total billed charges,,111,175.75,
Troponin-I,3004777,CDM,300,RC,84484,CPT,,,Inpatient,,,185,,,,80,,148,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,143.75,percent of total billed charges,,,95,,175.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,175.75,
"Rubella Antibodies, IgG LC",3004868,CDM,309,RC,86762,CPT,,,Outpatient,,,46,,,,80,,36.8,percent of total billed charges,,,,50,15.45,fee schedule,,,77.7,,35.74,percent of total billed charges,,,95,,43.7,percent of total billed charges,,,60,,27.6,percent of total billed charges,,27.6,43.7,
"Rubella Antibodies, IgG LC",3004868,CDM,309,RC,86762,CPT,,,Inpatient,,,46,,,,80,,36.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,35.74,percent of total billed charges,,,95,,43.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,43.7,
KOH,3005097,CDM,300,RC,87220,CPT,,,Outpatient,,,50,,,,80,,40,percent of total billed charges,,,,50,9.03,fee schedule,,,77.7,,38.85,percent of total billed charges,,,95,,47.5,percent of total billed charges,,,60,,30,percent of total billed charges,,30,47.5,
KOH,3005097,CDM,300,RC,87220,CPT,,,Inpatient,,,50,,,,80,,40,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,38.85,percent of total billed charges,,,95,,47.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,47.5,
"Carbamazepine (Tegretol), Serum - LC",3005378,CDM,309,RC,80156,CPT,,,Outpatient,,,215,,,,80,,172,percent of total billed charges,,,,50,45.82,fee schedule,,,77.7,,167.06,percent of total billed charges,,,95,,204.25,percent of total billed charges,,,60,,129,percent of total billed charges,,129,204.25,
"Carbamazepine (Tegretol), Serum - LC",3005378,CDM,309,RC,80156,CPT,,,Inpatient,,,215,,,,80,,172,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,167.06,percent of total billed charges,,,95,,204.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,204.25,
Urinalysis Dipstick,3005394,CDM,300,RC,81003,CPT,,,Outpatient,,,25,,,,80,,20,percent of total billed charges,,,,50,4.6,fee schedule,,,77.7,,19.43,percent of total billed charges,,,95,,23.75,percent of total billed charges,,,60,,15,percent of total billed charges,,15,23.75,
"Urinalysis with Microscopic, if indicated",3005394,CDM,300,RC,81003,CPT,,,Outpatient,,,25,,,,80,,20,percent of total billed charges,,,,50,4.6,fee schedule,,,77.7,,19.43,percent of total billed charges,,,95,,23.75,percent of total billed charges,,,60,,15,percent of total billed charges,,15,23.75,
Urinalysis Dipstick,3005394,CDM,300,RC,81003,CPT,,,Inpatient,,,25,,,,80,,20,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.43,percent of total billed charges,,,95,,23.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,23.75,
"Urinalysis with Microscopic, if indicated",3005394,CDM,300,RC,81003,CPT,,,Inpatient,,,25,,,,80,,20,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.43,percent of total billed charges,,,95,,23.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,23.75,
Anti-dsDNA Antibodies LC,3005816,CDM,309,RC,86225,CPT,,,Outpatient,,,168,,,,80,,134.4,percent of total billed charges,,,,50,30.38,fee schedule,,,77.7,,130.54,percent of total billed charges,,,95,,159.6,percent of total billed charges,,,60,,100.8,percent of total billed charges,,100.8,159.6,
Anti-dsDNA Antibodies LC,3005816,CDM,309,RC,86225,CPT,,,Inpatient,,,168,,,,80,,134.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,130.54,percent of total billed charges,,,95,,159.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,159.6,
Anti-Centromere B Antibodies LC,3005824,CDM,309,RC,86235,CPT,,,Outpatient,,,132,,,,80,,105.6,percent of total billed charges,,,,50,26.13,fee schedule,,,77.7,,102.56,percent of total billed charges,,,95,,125.4,percent of total billed charges,,,60,,79.2,percent of total billed charges,,79.2,125.4,
Anti-Centromere B Antibodies LC,3005824,CDM,309,RC,86235,CPT,,,Inpatient,,,132,,,,80,,105.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,102.56,percent of total billed charges,,,95,,125.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,125.4,
Thyroglobulin Antibody LC,3005832,CDM,309,RC,86800,CPT,,,Outpatient,,,190,,,,80,,152,percent of total billed charges,,,,50,34.54,fee schedule,,,77.7,,147.63,percent of total billed charges,,,95,,180.5,percent of total billed charges,,,60,,114,percent of total billed charges,,114,180.5,
Thyroglobulin Antibody LC,3005832,CDM,309,RC,86800,CPT,,,Inpatient,,,190,,,,80,,152,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,147.63,percent of total billed charges,,,95,,180.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,180.5,
Lupus Anticoagulant Comp LC,3005881,CDM,309,RC,85613,CPT,,,Outpatient,,,236,,,,80,,188.8,percent of total billed charges,,,,50,13.52,fee schedule,,,77.7,,183.37,percent of total billed charges,,,95,,224.2,percent of total billed charges,,,60,,141.6,percent of total billed charges,,141.6,224.2,
Lupus Anticoagulant Comp LC,3005881,CDM,309,RC,85613,CPT,,,Inpatient,,,236,,,,80,,188.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,183.37,percent of total billed charges,,,95,,224.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,224.2,
"Anticardiolip Ab, IgA/G/M, Qn LC",3005899,CDM,309,RC,86147,CPT,,,Outpatient,,,178,,,,80,,142.4,percent of total billed charges,,,,50,39.21,fee schedule,,,77.7,,138.31,percent of total billed charges,,,95,,169.1,percent of total billed charges,,,60,,106.8,percent of total billed charges,,106.8,169.1,
"Anticardiolipin Ab, IgA, Qn LC",3005899,CDM,309,RC,86147,CPT,,,Outpatient,,,137,,,,80,,109.6,percent of total billed charges,,,,50,39.21,fee schedule,,,77.7,,106.45,percent of total billed charges,,,95,,130.15,percent of total billed charges,,,60,,82.2,percent of total billed charges,,82.2,130.15,
"Anticardiolipin Ab, IgG/M, Qn LC",3005899,CDM,309,RC,86147,CPT,,,Outpatient,,,137,,,,80,,109.6,percent of total billed charges,,,,50,39.21,fee schedule,,,77.7,,106.45,percent of total billed charges,,,95,,130.15,percent of total billed charges,,,60,,82.2,percent of total billed charges,,82.2,130.15,
"Anticardiolip Ab, IgA/G/M, Qn LC",3005899,CDM,309,RC,86147,CPT,,,Inpatient,,,178,,,,80,,142.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,138.31,percent of total billed charges,,,95,,169.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,169.1,
"Anticardiolipin Ab, IgA, Qn LC",3005899,CDM,309,RC,86147,CPT,,,Inpatient,,,137,,,,80,,109.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,106.45,percent of total billed charges,,,95,,130.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,130.15,
"Anticardiolipin Ab, IgG/M, Qn LC",3005899,CDM,309,RC,86147,CPT,,,Inpatient,,,137,,,,80,,109.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,106.45,percent of total billed charges,,,95,,130.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,130.15,
TSH + Free T4 - LC,3006012,CDM,309,RC,84443,CPT,,,Outpatient,,,145,,,,80,,116,percent of total billed charges,,,,50,21.99,fee schedule,,,77.7,,112.67,percent of total billed charges,,,95,,137.75,percent of total billed charges,,,60,,87,percent of total billed charges,,87,137.75,
TSH LC,3006012,CDM,309,RC,84443,CPT,,,Outpatient,,,145,,,,80,,116,percent of total billed charges,,,,50,21.99,fee schedule,,,77.7,,112.67,percent of total billed charges,,,95,,137.75,percent of total billed charges,,,60,,87,percent of total billed charges,,87,137.75,
TSH + Free T4 - LC,3006012,CDM,309,RC,84443,CPT,,,Inpatient,,,145,,,,80,,116,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,112.67,percent of total billed charges,,,95,,137.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,137.75,
TSH LC,3006012,CDM,309,RC,84443,CPT,,,Inpatient,,,145,,,,80,,116,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,112.67,percent of total billed charges,,,95,,137.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,137.75,
Magnesium LC,3006319,CDM,309,RC,83735,CPT,,,Outpatient,,,112,,,,80,,89.6,percent of total billed charges,,,,50,12.93,fee schedule,,,77.7,,87.02,percent of total billed charges,,,95,,106.4,percent of total billed charges,,,60,,67.2,percent of total billed charges,,67.2,106.4,
Magnesium LC,3006319,CDM,309,RC,83735,CPT,,,Inpatient,,,112,,,,80,,89.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,87.02,percent of total billed charges,,,95,,106.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,106.4,
Anaerobic Cult 2 LC,3006509,CDM,309,RC,87076,CPT,,,Outpatient,,,75,,,,80,,60,percent of total billed charges,,,,50,15.33,fee schedule,,,77.7,,58.28,percent of total billed charges,,,95,,71.25,percent of total billed charges,,,60,,45,percent of total billed charges,,45,71.25,
Anaerobic Cult 2 LC,3006509,CDM,309,RC,87076,CPT,,,Inpatient,,,75,,,,80,,60,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,58.28,percent of total billed charges,,,95,,71.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,71.25,
ANA w/Reflex LC,3006525,CDM,309,RC,86038,CPT,,,Outpatient,,,116,,,,80,,92.8,percent of total billed charges,,,,50,22.15,fee schedule,,,77.7,,90.13,percent of total billed charges,,,95,,110.2,percent of total billed charges,,,60,,69.6,percent of total billed charges,,69.6,110.2,
ANA w/Reflex LC,3006525,CDM,309,RC,86038,CPT,,,Inpatient,,,116,,,,80,,92.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,90.13,percent of total billed charges,,,95,,110.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,110.2,
"Cytomegalovirus (CMV) Ab, IgG LC",3006582,CDM,309,RC,86644,CPT,,,Outpatient,,,195,,,,80,,156,percent of total billed charges,,,,50,36.06,fee schedule,,,77.7,,151.52,percent of total billed charges,,,95,,185.25,percent of total billed charges,,,60,,117,percent of total billed charges,,117,185.25,
"Cytomegalovirus (CMV) Ab, IgG LC",3006582,CDM,309,RC,86644,CPT,,,Inpatient,,,195,,,,80,,156,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,151.52,percent of total billed charges,,,95,,185.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,185.25,
"Complement C3, Serum LC",3006590,CDM,309,RC,86160,CPT,,,Outpatient,,,152,,,,80,,121.6,percent of total billed charges,,,,50,27.84,fee schedule,,,77.7,,118.1,percent of total billed charges,,,95,,144.4,percent of total billed charges,,,60,,91.2,percent of total billed charges,,91.2,144.4,
"Complement C3, Serum LC",3006590,CDM,309,RC,86160,CPT,,,Inpatient,,,152,,,,80,,121.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,118.1,percent of total billed charges,,,95,,144.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,144.4,
"Complement C4, Serum LC",3006608,CDM,309,RC,86160,CPT,,,Outpatient,,,152,,,,80,,121.6,percent of total billed charges,,,,50,27.84,fee schedule,,,77.7,,118.1,percent of total billed charges,,,95,,144.4,percent of total billed charges,,,60,,91.2,percent of total billed charges,,91.2,144.4,
"Complement C4, Serum LC",3006608,CDM,309,RC,86160,CPT,,,Inpatient,,,152,,,,80,,121.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,118.1,percent of total billed charges,,,95,,144.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,144.4,
Ova + Parasite Exam LC,3006921,CDM,309,RC,87177,CPT,,,Outpatient,,,70,,,,80,,56,percent of total billed charges,,,,50,15.71,fee schedule,,,77.7,,54.39,percent of total billed charges,,,95,,66.5,percent of total billed charges,,,60,,42,percent of total billed charges,,42,66.5,
Ova + Parasite Exam LC,3006921,CDM,309,RC,87177,CPT,,,Inpatient,,,70,,,,80,,56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,54.39,percent of total billed charges,,,95,,66.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,66.5,
Stool Culture LC,3007036,CDM,309,RC,87045,CPT,,,Outpatient,,,82,,,,80,,65.6,percent of total billed charges,,,,50,14.81,fee schedule,,,77.7,,63.71,percent of total billed charges,,,95,,77.9,percent of total billed charges,,,60,,49.2,percent of total billed charges,,49.2,77.9,
Stool Culture LC,3007036,CDM,309,RC,87045,CPT,,,Inpatient,,,82,,,,80,,65.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,63.71,percent of total billed charges,,,95,,77.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.9,
"Urine Culture, Routine LC",3007069,CDM,309,RC,87086,CPT,,,Outpatient,,,86,,,,80,,68.8,percent of total billed charges,,,,50,15.19,fee schedule,,,77.7,,66.82,percent of total billed charges,,,95,,81.7,percent of total billed charges,,,60,,51.6,percent of total billed charges,,51.6,81.7,
"Urine Culture, Routine LC",3007069,CDM,309,RC,87086,CPT,,,Inpatient,,,86,,,,80,,68.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,66.82,percent of total billed charges,,,95,,81.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,81.7,
Rheumatoid Arthritis Factor LC,3007093,CDM,309,RC,86431,CPT,,,Outpatient,,,70,,,,80,,56,percent of total billed charges,,,,50,12.87,fee schedule,,,77.7,,54.39,percent of total billed charges,,,95,,66.5,percent of total billed charges,,,60,,42,percent of total billed charges,,42,66.5,
Rheumatoid Arthritis Factor LC,3007093,CDM,309,RC,86431,CPT,,,Inpatient,,,70,,,,80,,56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,54.39,percent of total billed charges,,,95,,66.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,66.5,
DHEA-Sulfate LC,3007150,CDM,309,RC,82627,CPT,,,Outpatient,,,263,,,,80,,210.4,percent of total billed charges,,,,50,40.21,fee schedule,,,77.7,,204.35,percent of total billed charges,,,95,,249.85,percent of total billed charges,,,60,,157.8,percent of total billed charges,,157.8,249.85,
DHEA-Sulfate LC,3007150,CDM,309,RC,82627,CPT,,,Inpatient,,,263,,,,80,,210.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,204.35,percent of total billed charges,,,95,,249.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,249.85,
Myoglobin,3007218,CDM,300,RC,83874,CPT,,,Outpatient,,,127,,,,80,,101.6,percent of total billed charges,,,,50,23.83,fee schedule,,,77.7,,98.68,percent of total billed charges,,,95,,120.65,percent of total billed charges,,,60,,76.2,percent of total billed charges,,76.2,120.65,
Myoglobin,3007218,CDM,300,RC,83874,CPT,,,Inpatient,,,127,,,,80,,101.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,98.68,percent of total billed charges,,,95,,120.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,120.65,
T3 Uptake - LC,3007291,CDM,309,RC,84479,CPT,,,Outpatient,,,54,,,,80,,43.2,percent of total billed charges,,,,50,9.42,fee schedule,,,77.7,,41.96,percent of total billed charges,,,95,,51.3,percent of total billed charges,,,60,,32.4,percent of total billed charges,,32.4,51.3,
T3 Uptake - LC,3007291,CDM,309,RC,84479,CPT,,,Inpatient,,,54,,,,80,,43.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,41.96,percent of total billed charges,,,95,,51.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,51.3,
T4 and TSH LC,3007309,CDM,309,RC,84436,CPT,,,Outpatient,,,49,,,,80,,39.2,percent of total billed charges,,,,50,8.98,fee schedule,,,77.7,,38.07,percent of total billed charges,,,95,,46.55,percent of total billed charges,,,60,,29.4,percent of total billed charges,,29.4,46.55,
T4 and TSH LC,3007309,CDM,309,RC,84436,CPT,,,Inpatient,,,49,,,,80,,39.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,38.07,percent of total billed charges,,,95,,46.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,46.55,
"Catecholamines, Fractionated, Plasma - LC",3007747,CDM,309,RC,82384,CPT,,,Outpatient,,,314,,,,80,,251.2,percent of total billed charges,,,,50,58,fee schedule,,,77.7,,243.98,percent of total billed charges,,,95,,298.3,percent of total billed charges,,,60,,188.4,percent of total billed charges,,188.4,298.3,
"Catecholamines,Ur.,Free,24 Hr LC",3007747,CDM,309,RC,82384,CPT,,,Outpatient,,,269,,,,80,,215.2,percent of total billed charges,,,,50,58,fee schedule,,,77.7,,209.01,percent of total billed charges,,,95,,255.55,percent of total billed charges,,,60,,161.4,percent of total billed charges,,161.4,255.55,
"Catecholamines, Fractionated, Plasma - LC",3007747,CDM,309,RC,82384,CPT,,,Inpatient,,,314,,,,80,,251.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,243.98,percent of total billed charges,,,95,,298.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,298.3,
"Catecholamines,Ur.,Free,24 Hr LC",3007747,CDM,309,RC,82384,CPT,,,Inpatient,,,269,,,,80,,215.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,209.01,percent of total billed charges,,,95,,255.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,255.55,
"C-Peptide, Serum LC",3008471,CDM,309,RC,84681,CPT,,,Outpatient,,,174,,,,80,,139.2,percent of total billed charges,,,,50,33.32,fee schedule,,,77.7,,135.2,percent of total billed charges,,,95,,165.3,percent of total billed charges,,,60,,104.4,percent of total billed charges,,104.4,165.3,
"C-Peptide, Serum LC",3008471,CDM,309,RC,84681,CPT,,,Inpatient,,,174,,,,80,,139.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,135.2,percent of total billed charges,,,95,,165.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,165.3,
Complete Blood Count w/o Diff,3008794,CDM,300,RC,85027,CPT,,,Outpatient,,,33,,,,80,,26.4,percent of total billed charges,,,,50,6.95,fee schedule,,,77.7,,25.64,percent of total billed charges,,,95,,31.35,percent of total billed charges,,,60,,19.8,percent of total billed charges,,19.8,31.35,
Complete Blood Count w/o Diff,3008794,CDM,300,RC,85027,CPT,,,Inpatient,,,33,,,,80,,26.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,25.64,percent of total billed charges,,,95,,31.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,31.35,
Protein S-Antigen LC,3009016,CDM,309,RC,85305,CPT,,,Outpatient,,,75,,,,80,,60,percent of total billed charges,,,,50,15.14,fee schedule,,,77.7,,58.28,percent of total billed charges,,,95,,71.25,percent of total billed charges,,,60,,45,percent of total billed charges,,45,71.25,
Protein S-Antigen LC,3009016,CDM,309,RC,85305,CPT,,,Inpatient,,,75,,,,80,,60,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,58.28,percent of total billed charges,,,95,,71.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,71.25,
Protein C-Functional LC,3010055,CDM,309,RC,85303,CPT,,,Outpatient,,,137,,,,80,,109.6,percent of total billed charges,,,,50,42.85,fee schedule,,,77.7,,106.45,percent of total billed charges,,,95,,130.15,percent of total billed charges,,,60,,82.2,percent of total billed charges,,82.2,130.15,
Protein C-Functional LC,3010055,CDM,309,RC,85303,CPT,,,Inpatient,,,137,,,,80,,109.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,106.45,percent of total billed charges,,,95,,130.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,130.15,
"Erythropoietin (EPO), Serum LC",3010204,CDM,309,RC,82668,CPT,,,Outpatient,,,177,,,,80,,141.6,percent of total billed charges,,,,50,35.49,fee schedule,,,77.7,,137.53,percent of total billed charges,,,95,,168.15,percent of total billed charges,,,60,,106.2,percent of total billed charges,,106.2,168.15,
"Erythropoietin (EPO), Serum LC",3010204,CDM,309,RC,82668,CPT,,,Inpatient,,,177,,,,80,,141.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,137.53,percent of total billed charges,,,95,,168.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,168.15,
Ceruloplasmin LC,3010238,CDM,309,RC,82390,CPT,,,Outpatient,,,102,,,,80,,81.6,percent of total billed charges,,,,50,18.67,fee schedule,,,77.7,,79.25,percent of total billed charges,,,95,,96.9,percent of total billed charges,,,60,,61.2,percent of total billed charges,,61.2,96.9,
Ceruloplasmin LC,3010238,CDM,309,RC,82390,CPT,,,Inpatient,,,102,,,,80,,81.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,79.25,percent of total billed charges,,,95,,96.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,96.9,
Antistreptolysin O Ab LC,3010261,CDM,309,RC,86060,CPT,,,Outpatient,,,88,,,,80,,70.4,percent of total billed charges,,,,50,16.6,fee schedule,,,77.7,,68.38,percent of total billed charges,,,95,,83.6,percent of total billed charges,,,60,,52.8,percent of total billed charges,,52.8,83.6,
Antistreptolysin O Ab LC,3010261,CDM,309,RC,86060,CPT,,,Inpatient,,,88,,,,80,,70.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,68.38,percent of total billed charges,,,95,,83.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,83.6,
Transferrin - LC,3010360,CDM,309,RC,84466,CPT,,,Outpatient,,,166,,,,80,,132.8,percent of total billed charges,,,,50,38.97,fee schedule,,,77.7,,128.98,percent of total billed charges,,,95,,157.7,percent of total billed charges,,,60,,99.6,percent of total billed charges,,99.6,157.7,
Transferrin - LC,3010360,CDM,309,RC,84466,CPT,,,Inpatient,,,166,,,,80,,132.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,128.98,percent of total billed charges,,,95,,157.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,157.7,
"Alpha-1-Antitrypsin, Serum LC",3010626,CDM,309,RC,82103,CPT,,,Outpatient,,,141,,,,80,,112.8,percent of total billed charges,,,,50,25.4,fee schedule,,,77.7,,109.56,percent of total billed charges,,,95,,133.95,percent of total billed charges,,,60,,84.6,percent of total billed charges,,84.6,133.95,
"Alpha-1-Antitrypsin, Serum LC",3010626,CDM,309,RC,82103,CPT,,,Inpatient,,,141,,,,80,,112.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,109.56,percent of total billed charges,,,95,,133.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,133.95,
Electrolyte Panel,3010840,CDM,300,RC,80051,CPT,,,Outpatient,,,75,,,,80,,60,percent of total billed charges,,,,50,9.83,fee schedule,,,77.7,,58.28,percent of total billed charges,,,95,,71.25,percent of total billed charges,,,60,,45,percent of total billed charges,,45,71.25,
Electrolyte Panel,3010840,CDM,300,RC,80051,CPT,,,Inpatient,,,75,,,,80,,60,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,58.28,percent of total billed charges,,,95,,71.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,71.25,
Albumin/Creatinine Ratio Ur - LC,3010881,CDM,309,RC,82043,CPT,,,Outpatient,,,73,,,,80,,58.4,percent of total billed charges,,,,50,12.41,fee schedule,,,77.7,,56.72,percent of total billed charges,,,95,,69.35,percent of total billed charges,,,60,,43.8,percent of total billed charges,,43.8,69.35,
Albumin/Creatinine Ratio Ur - LC,3010881,CDM,309,RC,82043,CPT,,,Inpatient,,,73,,,,80,,58.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,56.72,percent of total billed charges,,,95,,69.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,69.35,
T pallidum Screen w/ Rflx - LC,3011087,CDM,309,RC,86780,CPT,,,Outpatient,,,70,,,,80,,56,percent of total billed charges,,,,50,26.56,fee schedule,,,77.7,,54.39,percent of total billed charges,,,95,,66.5,percent of total billed charges,,,60,,42,percent of total billed charges,,42,66.5,
T pallidum Screen w/ Rflx - LC,3011087,CDM,309,RC,86780,CPT,,,Inpatient,,,70,,,,80,,56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,54.39,percent of total billed charges,,,95,,66.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,66.5,
Growth Hormone - LC,3011103,CDM,309,RC,83003,CPT,,,Outpatient,,,148,,,,80,,118.4,percent of total billed charges,,,,50,29.48,fee schedule,,,77.7,,115,percent of total billed charges,,,95,,140.6,percent of total billed charges,,,60,,88.8,percent of total billed charges,,88.8,140.6,
Growth Hormone - LC,3011103,CDM,309,RC,83003,CPT,,,Inpatient,,,148,,,,80,,118.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,115,percent of total billed charges,,,95,,140.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,140.6,
"Varicella-Zoster V Ab, IgG LC",3011152,CDM,309,RC,86787,CPT,,,Outpatient,,,180,,,,80,,144,percent of total billed charges,,,,50,33.1,fee schedule,,,77.7,,139.86,percent of total billed charges,,,95,,171,percent of total billed charges,,,60,,108,percent of total billed charges,,108,171,
"Varicella-Zoster V Ab, IgG LC",3011152,CDM,309,RC,86787,CPT,,,Inpatient,,,180,,,,80,,144,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,139.86,percent of total billed charges,,,95,,171,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,171,
Microalbumin Level Urine,3013281,CDM,300,RC,82043,CPT,,,Outpatient,,,73,,,,80,,58.4,percent of total billed charges,,,,50,12.41,fee schedule,,,77.7,,56.72,percent of total billed charges,,,95,,69.35,percent of total billed charges,,,60,,43.8,percent of total billed charges,,43.8,69.35,
Microalbumin Level Urine,3013281,CDM,300,RC,82043,CPT,,,Inpatient,,,73,,,,80,,58.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,56.72,percent of total billed charges,,,95,,69.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,69.35,
Lithium - LC,3013364,CDM,309,RC,80178,CPT,,,Outpatient,,,72,,,,80,,57.6,percent of total billed charges,,,,50,13.22,fee schedule,,,77.7,,55.94,percent of total billed charges,,,95,,68.4,percent of total billed charges,,,60,,43.2,percent of total billed charges,,43.2,68.4,
Lithium - LC,3013364,CDM,309,RC,80178,CPT,,,Inpatient,,,72,,,,80,,57.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,55.94,percent of total billed charges,,,95,,68.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,68.4,
Phenytoin - LC,3013372,CDM,309,RC,80185,CPT,,,Outpatient,,,144,,,,80,,115.2,percent of total billed charges,,,,50,27.2,fee schedule,,,77.7,,111.89,percent of total billed charges,,,95,,136.8,percent of total billed charges,,,60,,86.4,percent of total billed charges,,86.4,136.8,
Phenytoin - LC,3013372,CDM,309,RC,80185,CPT,,,Inpatient,,,144,,,,80,,115.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,111.89,percent of total billed charges,,,95,,136.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,136.8,
Vancomycin Level Trough LC,3013422,CDM,309,RC,80202,CPT,,,Outpatient,,,154,,,,80,,123.2,percent of total billed charges,,,,50,29.48,fee schedule,,,77.7,,119.66,percent of total billed charges,,,95,,146.3,percent of total billed charges,,,60,,92.4,percent of total billed charges,,92.4,146.3,
Vancomycin Level Trough LC,3013422,CDM,309,RC,80202,CPT,,,Inpatient,,,154,,,,80,,123.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,119.66,percent of total billed charges,,,95,,146.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,146.3,
"Calcium, 24Hr Urine LC",3013471,CDM,309,RC,82340,CPT,,,Outpatient,,,72,,,,80,,57.6,percent of total billed charges,,,,50,11.14,fee schedule,,,77.7,,55.94,percent of total billed charges,,,95,,68.4,percent of total billed charges,,,60,,43.2,percent of total billed charges,,43.2,68.4,
"Calcium, 24Hr Urine LC",3013471,CDM,309,RC,82340,CPT,,,Inpatient,,,72,,,,80,,57.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,55.94,percent of total billed charges,,,95,,68.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,68.4,
CEA - LC,3013489,CDM,309,RC,82378,CPT,,,Outpatient,,,194,,,,80,,155.2,percent of total billed charges,,,,50,35.42,fee schedule,,,77.7,,150.74,percent of total billed charges,,,95,,184.3,percent of total billed charges,,,60,,116.4,percent of total billed charges,,116.4,184.3,
CEA - LC,3013489,CDM,309,RC,82378,CPT,,,Inpatient,,,194,,,,80,,155.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,150.74,percent of total billed charges,,,95,,184.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,184.3,
"Ferritin, Serum LC",3013521,CDM,309,RC,82728,CPT,,,Outpatient,,,148,,,,80,,118.4,percent of total billed charges,,,,50,26.62,fee schedule,,,77.7,,115,percent of total billed charges,,,95,,140.6,percent of total billed charges,,,60,,88.8,percent of total billed charges,,88.8,140.6,
"Ferritin, Serum LC",3013521,CDM,309,RC,82728,CPT,,,Inpatient,,,148,,,,80,,118.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,115,percent of total billed charges,,,95,,140.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,140.6,
"Osmolality, Urine LC",3013547,CDM,309,RC,83935,CPT,,,Outpatient,,,87,,,,80,,69.6,percent of total billed charges,,,,50,15.62,fee schedule,,,77.7,,67.6,percent of total billed charges,,,95,,82.65,percent of total billed charges,,,60,,52.2,percent of total billed charges,,52.2,82.65,
"Osmolality, Urine LC",3013547,CDM,309,RC,83935,CPT,,,Inpatient,,,87,,,,80,,69.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,67.6,percent of total billed charges,,,95,,82.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,82.65,
"Thyroxine (T4) Free, Direct, S LC",3013588,CDM,309,RC,84439,CPT,,,Outpatient,,,83,,,,80,,66.4,percent of total billed charges,,,,50,15.39,fee schedule,,,77.7,,64.49,percent of total billed charges,,,95,,78.85,percent of total billed charges,,,60,,49.8,percent of total billed charges,,49.8,78.85,
"Thyroxine (T4) Free, Direct, S LC",3013588,CDM,309,RC,84439,CPT,,,Inpatient,,,83,,,,80,,66.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,64.49,percent of total billed charges,,,95,,78.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,78.85,
Fibrinogen Activity LC,3013620,CDM,309,RC,85384,CPT,,,Outpatient,,,67,,,,80,,53.6,percent of total billed charges,,,,50,12.83,fee schedule,,,77.7,,52.06,percent of total billed charges,,,95,,63.65,percent of total billed charges,,,60,,40.2,percent of total billed charges,,40.2,63.65,
Fibrinogen Activity LC,3013620,CDM,309,RC,85384,CPT,,,Inpatient,,,67,,,,80,,53.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,52.06,percent of total billed charges,,,95,,63.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,63.65,
"C difficile Toxins A+B, EIA LC",3013711,CDM,309,RC,87324,CPT,,,Outpatient,,,151,,,,80,,120.8,percent of total billed charges,,,,50,27.42,fee schedule,,,77.7,,117.33,percent of total billed charges,,,95,,143.45,percent of total billed charges,,,60,,90.6,percent of total billed charges,,90.6,143.45,
"C difficile Toxins A+B, EIA LC",3013711,CDM,309,RC,87324,CPT,,,Inpatient,,,151,,,,80,,120.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,117.33,percent of total billed charges,,,95,,143.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,143.45,
"Triiodothyronine,Free,Serum LC",3013976,CDM,309,RC,84481,CPT,,,Outpatient,,,161,,,,80,,128.8,percent of total billed charges,,,,50,42.13,fee schedule,,,77.7,,125.1,percent of total billed charges,,,95,,152.95,percent of total billed charges,,,60,,96.6,percent of total billed charges,,96.6,152.95,
"Triiodothyronine,Free,Serum LC",3013976,CDM,309,RC,84481,CPT,,,Inpatient,,,161,,,,80,,128.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,125.1,percent of total billed charges,,,95,,152.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,152.95,
IGF-1 LC,3014057,CDM,309,RC,84305,CPT,,,Outpatient,,,302,,,,80,,241.6,percent of total billed charges,,,,50,60.37,fee schedule,,,77.7,,234.65,percent of total billed charges,,,95,,286.9,percent of total billed charges,,,60,,181.2,percent of total billed charges,,181.2,286.9,
IGF-1 LC,3014057,CDM,309,RC,84305,CPT,,,Inpatient,,,302,,,,80,,241.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,234.65,percent of total billed charges,,,95,,286.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,286.9,
"Rubeola Antibodies, IgG LC",3014560,CDM,309,RC,86765,CPT,,,Outpatient,,,145,,,,80,,116,percent of total billed charges,,,,50,34.14,fee schedule,,,77.7,,112.67,percent of total billed charges,,,95,,137.75,percent of total billed charges,,,60,,87,percent of total billed charges,,87,137.75,
"Rubeola Antibodies, IgG LC",3014560,CDM,309,RC,86765,CPT,,,Inpatient,,,145,,,,80,,116,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,112.67,percent of total billed charges,,,95,,137.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,137.75,
"Topiramate (Topamax), Serum LC",3014578,CDM,309,RC,80201,CPT,,,Outpatient,,,177,,,,80,,141.6,percent of total billed charges,,,,50,33.68,fee schedule,,,77.7,,137.53,percent of total billed charges,,,95,,168.15,percent of total billed charges,,,60,,106.2,percent of total billed charges,,106.2,168.15,
"Topiramate (Topamax), Serum LC",3014578,CDM,309,RC,80201,CPT,,,Inpatient,,,177,,,,80,,141.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,137.53,percent of total billed charges,,,95,,168.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,168.15,
"Mumps Antibodies, IgG LC",3014750,CDM,309,RC,86735,CPT,,,Outpatient,,,178,,,,80,,142.4,percent of total billed charges,,,,50,32.48,fee schedule,,,77.7,,138.31,percent of total billed charges,,,95,,169.1,percent of total billed charges,,,60,,106.8,percent of total billed charges,,106.8,169.1,
"Mumps Antibodies, IgG LC",3014750,CDM,309,RC,86735,CPT,,,Inpatient,,,178,,,,80,,142.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,138.31,percent of total billed charges,,,95,,169.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,169.1,
Blood Glucose Monitoring POC (GPHA),3015450,CDM,300,RC,82948,CPT,,,Outpatient,,,25,,,,80,,20,percent of total billed charges,,,,50,4.21,fee schedule,,,77.7,,19.43,percent of total billed charges,,,95,,23.75,percent of total billed charges,,,60,,15,percent of total billed charges,,15,23.75,
Blood Glucose Monitoring POC (GPHA),3015450,CDM,300,RC,82948,CPT,,,Inpatient,,,25,,,,80,,20,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.43,percent of total billed charges,,,95,,23.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,23.75,
Lipid Panel LC,3015682,CDM,309,RC,80061,CPT,,,Outpatient,,,192,,,,80,,153.6,percent of total billed charges,,,,50,21.59,fee schedule,,,77.7,,149.18,percent of total billed charges,,,95,,182.4,percent of total billed charges,,,60,,115.2,percent of total billed charges,,115.2,182.4,
Lipid Panel LC,3015682,CDM,309,RC,80061,CPT,,,Inpatient,,,192,,,,80,,153.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,149.18,percent of total billed charges,,,95,,182.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,182.4,
GGT - LC,3015815,CDM,309,RC,82977,CPT,,,Outpatient,,,107,,,,80,,85.6,percent of total billed charges,,,,50,7.73,fee schedule,,,77.7,,83.14,percent of total billed charges,,,95,,101.65,percent of total billed charges,,,60,,64.2,percent of total billed charges,,64.2,101.65,
GGT - LC,3015815,CDM,309,RC,82977,CPT,,,Inpatient,,,107,,,,80,,85.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,83.14,percent of total billed charges,,,95,,101.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,101.65,
Reticulocyte Count - LC,3017035,CDM,309,RC,85045,CPT,,,Outpatient,,,44,,,,80,,35.2,percent of total billed charges,,,,50,39.68,fee schedule,,,77.7,,34.19,percent of total billed charges,,,95,,41.8,percent of total billed charges,,,60,,26.4,percent of total billed charges,,26.4,41.8,
Reticulocyte Count - LC,3017035,CDM,309,RC,85045,CPT,,,Inpatient,,,44,,,,80,,35.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,34.19,percent of total billed charges,,,95,,41.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,41.8,
Vitamin B6 LC,3017050,CDM,309,RC,84207,CPT,,,Outpatient,,,377,,,,80,,301.6,percent of total billed charges,,,,50,70.26,fee schedule,,,77.7,,292.93,percent of total billed charges,,,95,,358.15,percent of total billed charges,,,60,,226.2,percent of total billed charges,,226.2,358.15,
Vitamin B6 LC,3017050,CDM,309,RC,84207,CPT,,,Inpatient,,,377,,,,80,,301.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,292.93,percent of total billed charges,,,95,,358.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,358.15,
Bilirubin Total,3017464,CDM,300,RC,82247,CPT,,,Outpatient,,,64,,,,80,,51.2,percent of total billed charges,,,,50,10.65,fee schedule,,,77.7,,49.73,percent of total billed charges,,,95,,60.8,percent of total billed charges,,,60,,38.4,percent of total billed charges,,38.4,60.8,
Bilirubin Total,3017464,CDM,300,RC,82247,CPT,,,Inpatient,,,64,,,,80,,51.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,49.73,percent of total billed charges,,,95,,60.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,60.8,
Bilirubin Direct,3017472,CDM,300,RC,82248,CPT,,,Outpatient,,,64,,,,80,,51.2,percent of total billed charges,,,,50,10.09,fee schedule,,,77.7,,49.73,percent of total billed charges,,,95,,60.8,percent of total billed charges,,,60,,38.4,percent of total billed charges,,38.4,60.8,
Bilirubin Direct,3017472,CDM,300,RC,82248,CPT,,,Inpatient,,,64,,,,80,,51.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,49.73,percent of total billed charges,,,95,,60.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,60.8,
"Tacrolimus (FK506), Blood LC",3017621,CDM,309,RC,80197,CPT,,,Outpatient,,,223,,,,80,,178.4,percent of total billed charges,,,,50,33.68,fee schedule,,,77.7,,173.27,percent of total billed charges,,,95,,211.85,percent of total billed charges,,,60,,133.8,percent of total billed charges,,133.8,211.85,
"Tacrolimus (FK506), Blood LC",3017621,CDM,309,RC,80197,CPT,,,Inpatient,,,223,,,,80,,178.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,173.27,percent of total billed charges,,,95,,211.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,211.85,
"Vitamin B1 (Thiamine), Blood LC",3018439,CDM,309,RC,84425,CPT,,,Outpatient,,,180,,,,80,,144,percent of total billed charges,,,,50,36.29,fee schedule,,,77.7,,139.86,percent of total billed charges,,,95,,171,percent of total billed charges,,,60,,108,percent of total billed charges,,108,171,
"Vitamin B1 (Thiamine), Blood LC",3018439,CDM,309,RC,84425,CPT,,,Inpatient,,,180,,,,80,,144,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,139.86,percent of total billed charges,,,95,,171,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,171,
"Reverse T3, Serum LC",3019379,CDM,309,RC,84482,CPT,,,Outpatient,,,198,,,,80,,158.4,percent of total billed charges,,,,50,41.46,fee schedule,,,77.7,,153.85,percent of total billed charges,,,95,,188.1,percent of total billed charges,,,60,,118.8,percent of total billed charges,,118.8,188.1,
"Reverse T3, Serum LC",3019379,CDM,309,RC,84482,CPT,,,Inpatient,,,198,,,,80,,158.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,153.85,percent of total billed charges,,,95,,188.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,188.1,
Thrombin Time LC,3019460,CDM,309,RC,85670,CPT,,,Outpatient,,,85,,,,80,,68,percent of total billed charges,,,,50,15.18,fee schedule,,,77.7,,66.05,percent of total billed charges,,,95,,80.75,percent of total billed charges,,,60,,51,percent of total billed charges,,51,80.75,
Thrombin Time LC,3019460,CDM,309,RC,85670,CPT,,,Inpatient,,,85,,,,80,,68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,66.05,percent of total billed charges,,,95,,80.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,80.75,
"HCV RNA by PCR, Qn Rfx Geno LC",3019643,CDM,309,RC,87522,CPT,,,Outpatient,,,332,,,,80,,265.6,percent of total billed charges,,,,50,45.96,fee schedule,,,77.7,,257.96,percent of total billed charges,,,95,,315.4,percent of total billed charges,,,60,,199.2,percent of total billed charges,,199.2,315.4,
"HCV RNA by PCR, Qn Rfx Geno LC",3019643,CDM,309,RC,87522,CPT,,,Inpatient,,,332,,,,80,,265.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,257.96,percent of total billed charges,,,95,,315.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,315.4,
H pylori IgG Abs LC,3020963,CDM,309,RC,86677,CPT,,,Outpatient,,,102,,,,80,,81.6,percent of total billed charges,,,,50,19.88,fee schedule,,,77.7,,79.25,percent of total billed charges,,,95,,96.9,percent of total billed charges,,,60,,61.2,percent of total billed charges,,61.2,96.9,
H pylori IgG Abs LC,3020963,CDM,309,RC,86677,CPT,,,Inpatient,,,102,,,,80,,81.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,79.25,percent of total billed charges,,,95,,96.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,96.9,
Helicobacter pylori IgM Ab LC,3020971,CDM,309,RC,86677,CPT,,,Outpatient,,,102,,,,80,,81.6,percent of total billed charges,,,,50,19.88,fee schedule,,,77.7,,79.25,percent of total billed charges,,,95,,96.9,percent of total billed charges,,,60,,61.2,percent of total billed charges,,61.2,96.9,
Helicobacter pylori IgM Ab LC,3020971,CDM,309,RC,86677,CPT,,,Inpatient,,,102,,,,80,,81.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,79.25,percent of total billed charges,,,95,,96.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,96.9,
"Helicobacter pylori, IgA LC",3020989,CDM,309,RC,86677,CPT,,,Outpatient,,,102,,,,80,,81.6,percent of total billed charges,,,,50,19.88,fee schedule,,,77.7,,79.25,percent of total billed charges,,,95,,96.9,percent of total billed charges,,,60,,61.2,percent of total billed charges,,61.2,96.9,
"Helicobacter pylori, IgA LC",3020989,CDM,309,RC,86677,CPT,,,Inpatient,,,102,,,,80,,81.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,79.25,percent of total billed charges,,,95,,96.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,96.9,
"H. pylori Stool Ag, EIA LC",3021607,CDM,309,RC,87338,CPT,,,Outpatient,,,164,,,,80,,131.2,percent of total billed charges,,,,50,15.59,fee schedule,,,77.7,,127.43,percent of total billed charges,,,95,,155.8,percent of total billed charges,,,60,,98.4,percent of total billed charges,,98.4,155.8,
"H. pylori Stool Ag, EIA LC",3021607,CDM,309,RC,87338,CPT,,,Inpatient,,,164,,,,80,,131.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,127.43,percent of total billed charges,,,95,,155.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,155.8,
Basic Metabolic Panel,3021615,CDM,300,RC,80048,CPT,,,Outpatient,,,157,,,,80,,125.6,percent of total billed charges,,,,50,9.83,fee schedule,,,77.7,,121.99,percent of total billed charges,,,95,,149.15,percent of total billed charges,,,60,,94.2,percent of total billed charges,,94.2,149.15,
Basic Metabolic Panel,3021615,CDM,300,RC,80048,CPT,,,Inpatient,,,157,,,,80,,125.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,121.99,percent of total billed charges,,,95,,149.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,149.15,
Comprehensive Metabolic Panel,3021623,CDM,300,RC,80053,CPT,,,Outpatient,,,277,,,,80,,221.6,percent of total billed charges,,,,50,11.34,fee schedule,,,77.7,,215.23,percent of total billed charges,,,95,,263.15,percent of total billed charges,,,60,,166.2,percent of total billed charges,,166.2,263.15,
Comprehensive Metabolic Panel,3021623,CDM,300,RC,80053,CPT,,,Inpatient,,,277,,,,80,,221.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,215.23,percent of total billed charges,,,95,,263.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,263.15,
Hepatic Function Panel,3021631,CDM,300,RC,80076,CPT,,,Outpatient,,,157,,,,80,,125.6,percent of total billed charges,,,,50,15.94,fee schedule,,,77.7,,121.99,percent of total billed charges,,,95,,149.15,percent of total billed charges,,,60,,94.2,percent of total billed charges,,94.2,149.15,
Hepatic Function Panel,3021631,CDM,300,RC,80076,CPT,,,Inpatient,,,157,,,,80,,125.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,121.99,percent of total billed charges,,,95,,149.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,149.15,
Renal Function Panel,3021649,CDM,300,RC,80069,CPT,,,Outpatient,,,194,,,,80,,155.2,percent of total billed charges,,,,50,10.16,fee schedule,,,77.7,,150.74,percent of total billed charges,,,95,,184.3,percent of total billed charges,,,60,,116.4,percent of total billed charges,,116.4,184.3,
Renal Function Panel,3021649,CDM,300,RC,80069,CPT,,,Inpatient,,,194,,,,80,,155.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,150.74,percent of total billed charges,,,95,,184.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,184.3,
"Methylmalonic Acid, Serum LC",3021698,CDM,309,RC,83921,CPT,,,Outpatient,,,250,,,,80,,200,percent of total billed charges,,,,50,21.5,fee schedule,,,77.7,,194.25,percent of total billed charges,,,95,,237.5,percent of total billed charges,,,60,,150,percent of total billed charges,,150,237.5,
"Methylmalonic Acid, Serum LC",3021698,CDM,309,RC,83921,CPT,,,Inpatient,,,250,,,,80,,200,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,194.25,percent of total billed charges,,,95,,237.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,237.5,
Glucose Cerebrospinal Fluid,3023306,CDM,300,RC,82945,CPT,,,Outpatient,,,60,,,,80,,48,percent of total billed charges,,,,50,7.14,fee schedule,,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,60,,36,percent of total billed charges,,36,57,
Glucose Cerebrospinal Fluid,3023306,CDM,300,RC,82945,CPT,,,Inpatient,,,60,,,,80,,48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,57,
"Organism ID, Bacteria LC",3023322,CDM,309,RC,87077,CPT,,,Outpatient,,,85,,,,80,,68,percent of total billed charges,,,,50,15.33,fee schedule,,,77.7,,66.05,percent of total billed charges,,,95,,80.75,percent of total billed charges,,,60,,51,percent of total billed charges,,51,80.75,
"Organism ID, Bacteria LC",3023322,CDM,309,RC,87077,CPT,,,Inpatient,,,85,,,,80,,68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,66.05,percent of total billed charges,,,95,,80.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,80.75,
"Stool Culture, Yersinia Only LC",3023496,CDM,309,RC,87046,CPT,,,Outpatient,,,68,,,,80,,54.4,percent of total billed charges,,,,50,14.81,fee schedule,,,77.7,,52.84,percent of total billed charges,,,95,,64.6,percent of total billed charges,,,60,,40.8,percent of total billed charges,,40.8,64.6,
"Stool Culture, Yersinia Only LC",3023496,CDM,309,RC,87046,CPT,,,Inpatient,,,68,,,,80,,54.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,52.84,percent of total billed charges,,,95,,64.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,64.6,
CA 27.29 LC,3023785,CDM,309,RC,86300,CPT,,,Outpatient,,,227,,,,80,,181.6,percent of total billed charges,,,,50,27.42,fee schedule,,,77.7,,176.38,percent of total billed charges,,,95,,215.65,percent of total billed charges,,,60,,136.2,percent of total billed charges,,136.2,215.65,
CA 27.29 LC,3023785,CDM,309,RC,86300,CPT,,,Inpatient,,,227,,,,80,,181.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,176.38,percent of total billed charges,,,95,,215.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,215.65,
Cancer Antigen (CA) 125 LC,3023819,CDM,309,RC,86304,CPT,,,Outpatient,,,118,,,,80,,94.4,percent of total billed charges,,,,50,27.39,fee schedule,,,77.7,,91.69,percent of total billed charges,,,95,,112.1,percent of total billed charges,,,60,,70.8,percent of total billed charges,,70.8,112.1,
Cancer Antigen (CA) 125 LC,3023819,CDM,309,RC,86304,CPT,,,Inpatient,,,118,,,,80,,94.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,91.69,percent of total billed charges,,,95,,112.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,112.1,
"Vitamin A, Serum LC",3024189,CDM,309,RC,84590,CPT,,,Outpatient,,,150,,,,80,,120,percent of total billed charges,,,,50,23.45,fee schedule,,,77.7,,116.55,percent of total billed charges,,,95,,142.5,percent of total billed charges,,,60,,90,percent of total billed charges,,90,142.5,
"Vitamin A, Serum LC",3024189,CDM,309,RC,84590,CPT,,,Inpatient,,,150,,,,80,,120,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,116.55,percent of total billed charges,,,95,,142.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,142.5,
"Homocyst(e)ine, Plasma LC",3024270,CDM,309,RC,83090,CPT,,,Outpatient,,,453,,,,80,,362.4,percent of total billed charges,,,,50,88.29,fee schedule,,,77.7,,351.98,percent of total billed charges,,,95,,430.35,percent of total billed charges,,,60,,271.8,percent of total billed charges,,271.8,430.35,
"Homocyst(e)ine, Plasma LC",3024270,CDM,309,RC,83090,CPT,,,Inpatient,,,453,,,,80,,362.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,351.98,percent of total billed charges,,,95,,430.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,430.35,
B-Type Natriuretic Peptide,3025731,CDM,300,RC,83880,CPT,,,Outpatient,,,259,,,,80,,207.2,percent of total billed charges,,,,50,36.42,fee schedule,,,77.7,,201.24,percent of total billed charges,,,95,,246.05,percent of total billed charges,,,60,,155.4,percent of total billed charges,,155.4,246.05,
B-Type Natriuretic Peptide,3025731,CDM,300,RC,83880,CPT,,,Inpatient,,,259,,,,80,,207.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,201.24,percent of total billed charges,,,95,,246.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,246.05,
Thyroid Antibodies LC,3026002,CDM,309,RC,86376,CPT,,,Outpatient,,,129,,,,80,,103.2,percent of total billed charges,,,,50,25.48,fee schedule,,,77.7,,100.23,percent of total billed charges,,,95,,122.55,percent of total billed charges,,,60,,77.4,percent of total billed charges,,77.4,122.55,
Thyroid Peroxidase (TPO) Ab LC,3026002,CDM,309,RC,86376,CPT,,,Outpatient,,,129,,,,80,,103.2,percent of total billed charges,,,,50,25.48,fee schedule,,,77.7,,100.23,percent of total billed charges,,,95,,122.55,percent of total billed charges,,,60,,77.4,percent of total billed charges,,77.4,122.55,
Thyroid Antibodies LC,3026002,CDM,309,RC,86376,CPT,,,Inpatient,,,129,,,,80,,103.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,100.23,percent of total billed charges,,,95,,122.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,122.55,
Thyroid Peroxidase (TPO) Ab LC,3026002,CDM,309,RC,86376,CPT,,,Inpatient,,,129,,,,80,,103.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,100.23,percent of total billed charges,,,95,,122.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,122.55,
Estrone - LC,3026291,CDM,309,RC,82679,CPT,,,Outpatient,,,230,,,,80,,184,percent of total billed charges,,,,50,31.05,fee schedule,,,77.7,,178.71,percent of total billed charges,,,95,,218.5,percent of total billed charges,,,60,,138,percent of total billed charges,,138,218.5,
Estrone - LC,3026291,CDM,309,RC,82679,CPT,,,Inpatient,,,230,,,,80,,184,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,178.71,percent of total billed charges,,,95,,218.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,218.5,
CA 19-9 LC,3026960,CDM,309,RC,86301,CPT,,,Outpatient,,,194,,,,80,,155.2,percent of total billed charges,,,,50,27.26,fee schedule,,,77.7,,150.74,percent of total billed charges,,,95,,184.3,percent of total billed charges,,,60,,116.4,percent of total billed charges,,116.4,184.3,
CA 19-9 LC,3026960,CDM,309,RC,86301,CPT,,,Inpatient,,,194,,,,80,,155.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,150.74,percent of total billed charges,,,95,,184.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,184.3,
hsCRP,3027588,CDM,300,RC,86141,CPT,,,Outpatient,,,163,,,,80,,130.4,percent of total billed charges,,,,50,30.64,fee schedule,,,77.7,,126.65,percent of total billed charges,,,95,,154.85,percent of total billed charges,,,60,,97.8,percent of total billed charges,,97.8,154.85,
hsCRP,3027588,CDM,300,RC,86141,CPT,,,Inpatient,,,163,,,,80,,130.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,126.65,percent of total billed charges,,,95,,154.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,154.85,
"Rocky Mtn Spotted Fever, IgM LC",3027695,CDM,309,RC,86757,CPT,,,Outpatient,,,328,,,,80,,262.4,percent of total billed charges,,,,50,63.27,fee schedule,,,77.7,,254.86,percent of total billed charges,,,95,,311.6,percent of total billed charges,,,60,,196.8,percent of total billed charges,,196.8,311.6,
"Rocky Mtn Spotted Fever, IgM LC",3027695,CDM,309,RC,86757,CPT,,,Inpatient,,,328,,,,80,,262.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,254.86,percent of total billed charges,,,95,,311.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,311.6,
"IFE+Protein Electro, 24-Hr Ur LC",3028461,CDM,309,RC,84156,CPT,,,Outpatient,,,44,,,,80,,35.2,percent of total billed charges,,,,50,9.41,fee schedule,,,77.7,,34.19,percent of total billed charges,,,95,,41.8,percent of total billed charges,,,60,,26.4,percent of total billed charges,,26.4,41.8,
"IFE+Protein Electro, 24-Hr Ur LC",3028461,CDM,309,RC,84156,CPT,,,Inpatient,,,44,,,,80,,35.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,34.19,percent of total billed charges,,,95,,41.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,41.8,
Giardia/Cryptosporidium EIA - LC,3029113,CDM,309,RC,87329,CPT,,,Outpatient,,,197,,,,80,,157.6,percent of total billed charges,,,,50,30.18,fee schedule,,,77.7,,153.07,percent of total billed charges,,,95,,187.15,percent of total billed charges,,,60,,118.2,percent of total billed charges,,118.2,187.15,
Giardia/Cryptosporidium EIA - LC,3029113,CDM,309,RC,87329,CPT,,,Inpatient,,,197,,,,80,,157.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,153.07,percent of total billed charges,,,95,,187.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,187.15,
Protein Urine,3029139,CDM,300,RC,84156,CPT,,,Outpatient,,,44,,,,80,,35.2,percent of total billed charges,,,,50,9.41,fee schedule,,,77.7,,34.19,percent of total billed charges,,,95,,41.8,percent of total billed charges,,,60,,26.4,percent of total billed charges,,26.4,41.8,
Protein Urine,3029139,CDM,300,RC,84156,CPT,,,Inpatient,,,44,,,,80,,35.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,34.19,percent of total billed charges,,,95,,41.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,41.8,
Protein Cerebrospinal Fluid,3029287,CDM,300,RC,84157,CPT,,,Outpatient,,,44,,,,80,,35.2,percent of total billed charges,,,,50,9.41,fee schedule,,,77.7,,34.19,percent of total billed charges,,,95,,41.8,percent of total billed charges,,,60,,26.4,percent of total billed charges,,26.4,41.8,
Protein Cerebrospinal Fluid,3029287,CDM,300,RC,84157,CPT,,,Inpatient,,,44,,,,80,,35.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,34.19,percent of total billed charges,,,95,,41.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,41.8,
Rapid Occult Blood Diagnostic Stool,3029451,CDM,300,RC,82272,CPT,,,Outpatient,,,36,,,,80,,28.8,percent of total billed charges,,,,50,3.49,fee schedule,,,77.7,,27.97,percent of total billed charges,,,95,,34.2,percent of total billed charges,,,60,,21.6,percent of total billed charges,,21.6,34.2,
Rapid Occult Blood Diagnostic Stool,3029451,CDM,300,RC,82272,CPT,,,Inpatient,,,36,,,,80,,28.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,27.97,percent of total billed charges,,,95,,34.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,34.2,
CCP Antibodies IgG/IgA LC,3029493,CDM,309,RC,86200,CPT,,,Outpatient,,,63,,,,80,,50.4,percent of total billed charges,,,,50,13.9,fee schedule,,,77.7,,48.95,percent of total billed charges,,,95,,59.85,percent of total billed charges,,,60,,37.8,percent of total billed charges,,37.8,59.85,
CCP Antibodies IgG/IgA LC,3029493,CDM,309,RC,86200,CPT,,,Inpatient,,,63,,,,80,,50.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,48.95,percent of total billed charges,,,95,,59.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,59.85,
D-Dimer,3030426,CDM,300,RC,85378,CPT,,,Outpatient,,,174,,,,80,,139.2,percent of total billed charges,,,,50,24.15,fee schedule,,,77.7,,135.2,percent of total billed charges,,,95,,165.3,percent of total billed charges,,,60,,104.4,percent of total billed charges,,104.4,165.3,
D-Dimer,3030426,CDM,300,RC,85378,CPT,,,Inpatient,,,174,,,,80,,139.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,135.2,percent of total billed charges,,,95,,165.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,165.3,
QuantiFERON-TB Gold Plus - LC,3031036,CDM,309,RC,86480,CPT,,,Outpatient,,,166,,,,80,,132.8,percent of total billed charges,,,,50,66.5,fee schedule,,,77.7,,128.98,percent of total billed charges,,,95,,157.7,percent of total billed charges,,,60,,99.6,percent of total billed charges,,99.6,157.7,
QuantiFERON-TB Gold Plus - LC,3031036,CDM,309,RC,86480,CPT,,,Inpatient,,,166,,,,80,,132.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,128.98,percent of total billed charges,,,95,,157.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,157.7,
Actin (Smooth Muscle) Antibody LC,3031101,CDM,309,RC,83516,CPT,,,Outpatient,,,95,,,,80,,76,percent of total billed charges,,,,50,22.67,fee schedule,,,77.7,,73.82,percent of total billed charges,,,95,,90.25,percent of total billed charges,,,60,,57,percent of total billed charges,,57,90.25,
Actin (Smooth Muscle) Antibody LC,3031101,CDM,309,RC,83516,CPT,,,Inpatient,,,95,,,,80,,76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,73.82,percent of total billed charges,,,95,,90.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,90.25,
"Calprotectin, Fecal - LC",3031358,CDM,309,RC,83993,CPT,,,Outpatient,,,340,,,,80,,272,percent of total billed charges,,,,50,12.28,fee schedule,,,77.7,,264.18,percent of total billed charges,,,95,,323,percent of total billed charges,,,60,,204,percent of total billed charges,,204,323,
"Calprotectin, Fecal - LC",3031358,CDM,309,RC,83993,CPT,,,Inpatient,,,340,,,,80,,272,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,264.18,percent of total billed charges,,,95,,323,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,323,
UA Microscopic,3031903,CDM,300,RC,81015,CPT,,,Outpatient,,,30,,,,80,,24,percent of total billed charges,,,,50,4.88,fee schedule,,,77.7,,23.31,percent of total billed charges,,,95,,28.5,percent of total billed charges,,,60,,18,percent of total billed charges,,18,28.5,
Urine Microscopic Exam - LC,3031903,CDM,309,RC,81015,CPT,,,Outpatient,,,30,,,,80,,24,percent of total billed charges,,,,50,4.88,fee schedule,,,77.7,,23.31,percent of total billed charges,,,95,,28.5,percent of total billed charges,,,60,,18,percent of total billed charges,,18,28.5,
UA Microscopic,3031903,CDM,300,RC,81015,CPT,,,Inpatient,,,30,,,,80,,24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,23.31,percent of total billed charges,,,95,,28.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,28.5,
Urine Microscopic Exam - LC,3031903,CDM,309,RC,81015,CPT,,,Inpatient,,,30,,,,80,,24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,23.31,percent of total billed charges,,,95,,28.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,28.5,
E coli Shiga Toxin EIA LC,3032430,CDM,309,RC,87427,CPT,,,Outpatient,,,105,,,,80,,84,percent of total billed charges,,,,50,27.42,fee schedule,,,77.7,,81.59,percent of total billed charges,,,95,,99.75,percent of total billed charges,,,60,,63,percent of total billed charges,,63,99.75,
E coli Shiga Toxin EIA LC,3032430,CDM,309,RC,87427,CPT,,,Inpatient,,,105,,,,80,,84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,81.59,percent of total billed charges,,,95,,99.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,99.75,
"Pancreatic Elastase, Fecal - LC",3033115,CDM,309,RC,82656,CPT,,,Outpatient,,,346,,,,80,,276.8,percent of total billed charges,,,,50,12.76,fee schedule,,,77.7,,268.84,percent of total billed charges,,,95,,328.7,percent of total billed charges,,,60,,207.6,percent of total billed charges,,207.6,328.7,
"Pancreatic Elastase, Fecal - LC",3033115,CDM,309,RC,82656,CPT,,,Inpatient,,,346,,,,80,,276.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,268.84,percent of total billed charges,,,95,,328.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,328.7,
Prealbumin Level,3033180,CDM,300,RC,84134,CPT,,,Outpatient,,,129,,,,80,,103.2,percent of total billed charges,,,,50,24.41,fee schedule,,,77.7,,100.23,percent of total billed charges,,,95,,122.55,percent of total billed charges,,,60,,77.4,percent of total billed charges,,77.4,122.55,
Prealbumin Level,3033180,CDM,300,RC,84134,CPT,,,Inpatient,,,129,,,,80,,103.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,100.23,percent of total billed charges,,,95,,122.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,122.55,
Lactic Acid,3033339,CDM,300,RC,83605,CPT,,,Outpatient,,,132,,,,80,,105.6,percent of total billed charges,,,,50,23.68,fee schedule,,,77.7,,102.56,percent of total billed charges,,,95,,125.4,percent of total billed charges,,,60,,79.2,percent of total billed charges,,79.2,125.4,
Lactic Acid,3033339,CDM,300,RC,83605,CPT,,,Inpatient,,,132,,,,80,,105.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,102.56,percent of total billed charges,,,95,,125.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,125.4,
t-Transglutaminase (tTG) IgA LC,3033487,CDM,309,RC,83516,CPT,,,Outpatient,,,141,,,,80,,112.8,percent of total billed charges,,,,50,22.67,fee schedule,,,77.7,,109.56,percent of total billed charges,,,95,,133.95,percent of total billed charges,,,60,,84.6,percent of total billed charges,,84.6,133.95,
t-Transglutaminase (tTG) IgA LC,3033487,CDM,309,RC,83516,CPT,,,Inpatient,,,141,,,,80,,112.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,109.56,percent of total billed charges,,,95,,133.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,133.95,
t-Transglutaminase (tTG) IgG LC,3033495,CDM,309,RC,83516,CPT,,,Outpatient,,,87,,,,80,,69.6,percent of total billed charges,,,,50,22.67,fee schedule,,,77.7,,67.6,percent of total billed charges,,,95,,82.65,percent of total billed charges,,,60,,52.2,percent of total billed charges,,52.2,82.65,
t-Transglutaminase (tTG) IgG LC,3033495,CDM,309,RC,83516,CPT,,,Inpatient,,,87,,,,80,,69.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,67.6,percent of total billed charges,,,95,,82.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,82.65,
Valproic Acid (Depakote) - LC,3034840,CDM,309,RC,80164,CPT,,,Outpatient,,,170,,,,80,,136,percent of total billed charges,,,,50,32.75,fee schedule,,,77.7,,132.09,percent of total billed charges,,,95,,161.5,percent of total billed charges,,,60,,102,percent of total billed charges,,102,161.5,
Valproic Acid (Depakote) - LC,3034840,CDM,309,RC,80164,CPT,,,Inpatient,,,170,,,,80,,136,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,132.09,percent of total billed charges,,,95,,161.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,161.5,
"Hered.Hemochromatosis, DNA LC",3035029,CDM,309,RC,81256,CPT,,,Outpatient,,,471,,,,80,,376.8,percent of total billed charges,,,,50,189.65,fee schedule,,,77.7,,365.97,percent of total billed charges,,,95,,447.45,percent of total billed charges,,,60,,282.6,percent of total billed charges,,282.6,447.45,
"Hered.Hemochromatosis, DNA LC",3035029,CDM,309,RC,81256,CPT,,,Inpatient,,,471,,,,80,,376.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,365.97,percent of total billed charges,,,95,,447.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,447.45,
"Immunoglobulin A, Qn, Serum LC",3035748,CDM,309,RC,82784,CPT,,,Outpatient,,,137,,,,80,,109.6,percent of total billed charges,,,,50,24.62,fee schedule,,,77.7,,106.45,percent of total billed charges,,,95,,130.15,percent of total billed charges,,,60,,82.2,percent of total billed charges,,82.2,130.15,
"Immunoglobulin G, Qn, Serum LC",3035748,CDM,309,RC,82784,CPT,,,Outpatient,,,137,,,,80,,109.6,percent of total billed charges,,,,50,24.62,fee schedule,,,77.7,,106.45,percent of total billed charges,,,95,,130.15,percent of total billed charges,,,60,,82.2,percent of total billed charges,,82.2,130.15,
"Immunoglobulin A, Qn, Serum LC",3035748,CDM,309,RC,82784,CPT,,,Inpatient,,,137,,,,80,,109.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,106.45,percent of total billed charges,,,95,,130.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,130.15,
"Immunoglobulin G, Qn, Serum LC",3035748,CDM,309,RC,82784,CPT,,,Inpatient,,,137,,,,80,,109.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,106.45,percent of total billed charges,,,95,,130.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,130.15,
"hCG,Beta Subunit, Qnt, Serum LC",3036050,CDM,309,RC,84702,CPT,,,Outpatient,,,170,,,,80,,136,percent of total billed charges,,,,50,30.18,fee schedule,,,77.7,,132.09,percent of total billed charges,,,95,,161.5,percent of total billed charges,,,60,,102,percent of total billed charges,,102,161.5,
"hCG,Beta Subunit, Qnt, Serum LC",3036050,CDM,309,RC,84702,CPT,,,Inpatient,,,170,,,,80,,136,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,132.09,percent of total billed charges,,,95,,161.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,161.5,
"Amphetamine Confirmation, Ur LC",3036373,CDM,309,RC,80324,CPT,,,Outpatient,,,56,,,,80,,44.8,percent of total billed charges,,,,50,18.57,fee schedule,,,77.7,,43.51,percent of total billed charges,,,95,,53.2,percent of total billed charges,,,60,,33.6,percent of total billed charges,,33.6,53.2,
"Amphetamine Confirmation, Ur LC",3036373,CDM,309,RC,80324,CPT,,,Inpatient,,,56,,,,80,,44.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,43.51,percent of total billed charges,,,95,,53.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,53.2,
".Benzodiazepine Confirmation,Ur LC",3036522,CDM,309,RC,80346,CPT,,,Outpatient,,,68,,,,80,,54.4,percent of total billed charges,,,,50,27.38,fee schedule,,,77.7,,52.84,percent of total billed charges,,,95,,64.6,percent of total billed charges,,,60,,40.8,percent of total billed charges,,40.8,64.6,
".Benzodiazepine Confirmation,Ur LC",3036522,CDM,309,RC,80346,CPT,,,Inpatient,,,68,,,,80,,54.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,52.84,percent of total billed charges,,,95,,64.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,64.6,
Panel 083935 LC,3037017,CDM,309,RC,87389,CPT,,,Outpatient,,,168,,,,80,,134.4,percent of total billed charges,,,,50,30.01,fee schedule,,,77.7,,130.54,percent of total billed charges,,,95,,159.6,percent of total billed charges,,,60,,100.8,percent of total billed charges,,100.8,159.6,
Panel 083935 LC,3037017,CDM,309,RC,87389,CPT,,,Inpatient,,,168,,,,80,,134.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,130.54,percent of total billed charges,,,95,,159.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,159.6,
XR Mandible Complete Minimum 4 Views,3200037,CDM,320,RC,70110,CPT,,,Outpatient,,,343,,,,80,,274.4,percent of total billed charges,,,,50,105.47,fee schedule,,,77.7,,266.51,percent of total billed charges,,,95,,325.85,percent of total billed charges,,,60,,205.8,percent of total billed charges,,205.8,325.85,
XR Mandible Complete Minimum 4 Views,3200037,CDM,320,RC,70110,CPT,,,Inpatient,,,343,,,,80,,274.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,266.51,percent of total billed charges,,,95,,325.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,325.85,
XR Facial Bones Minimum 3 Views,3200078,CDM,320,RC,70150,CPT,,,Outpatient,,,248,,,,80,,198.4,percent of total billed charges,,,,50,94.78,fee schedule,,,77.7,,192.7,percent of total billed charges,,,95,,235.6,percent of total billed charges,,,60,,148.8,percent of total billed charges,,148.8,235.6,
XR Facial Bones Minimum 3 Views,3200078,CDM,320,RC,70150,CPT,,,Inpatient,,,248,,,,80,,198.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,192.7,percent of total billed charges,,,95,,235.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,235.6,
XR Nasal Bones Minimum 3 Views,3200086,CDM,320,RC,70160,CPT,,,Outpatient,,,224,,,,80,,179.2,percent of total billed charges,,,,50,73.87,fee schedule,,,77.7,,174.05,percent of total billed charges,,,95,,212.8,percent of total billed charges,,,60,,134.4,percent of total billed charges,,134.4,212.8,
XR Nasal Bones Minimum 3 Views,3200086,CDM,320,RC,70160,CPT,,,Inpatient,,,224,,,,80,,179.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,174.05,percent of total billed charges,,,95,,212.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,212.8,
XR Skull < 4 Views,3200151,CDM,320,RC,70250,CPT,,,Outpatient,,,196,,,,80,,156.8,percent of total billed charges,,,,50,71.55,fee schedule,,,77.7,,152.29,percent of total billed charges,,,95,,186.2,percent of total billed charges,,,60,,117.6,percent of total billed charges,,117.6,186.2,
XR Skull < 4 Views,3200151,CDM,320,RC,70250,CPT,,,Inpatient,,,196,,,,80,,156.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,152.29,percent of total billed charges,,,95,,186.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,186.2,
XR Skull Complete,3200169,CDM,320,RC,70260,CPT,,,Outpatient,,,283,,,,80,,226.4,percent of total billed charges,,,,50,105.47,fee schedule,,,77.7,,219.89,percent of total billed charges,,,95,,268.85,percent of total billed charges,,,60,,169.8,percent of total billed charges,,169.8,268.85,
XR Skull Complete,3200169,CDM,320,RC,70260,CPT,,,Inpatient,,,283,,,,80,,226.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,219.89,percent of total billed charges,,,95,,268.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,268.85,
XR Neck Soft Tissue,3200185,CDM,320,RC,70360,CPT,,,Outpatient,,,195,,,,80,,156,percent of total billed charges,,,,50,64.58,fee schedule,,,77.7,,151.52,percent of total billed charges,,,95,,185.25,percent of total billed charges,,,60,,117,percent of total billed charges,,117,185.25,
XR Neck Soft Tissue,3200185,CDM,320,RC,70360,CPT,,,Inpatient,,,195,,,,80,,156,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,151.52,percent of total billed charges,,,95,,185.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,185.25,
XR Ribs 2 Views Left,3200276,CDM,320,RC,71100,CPT,,,Outpatient,,,239,,,,80,,191.2,percent of total billed charges,,,,50,66.9,fee schedule,,,77.7,,185.7,percent of total billed charges,,,95,,227.05,percent of total billed charges,,,60,,143.4,percent of total billed charges,,143.4,227.05,
XR Ribs 2 Views Left,3200276,CDM,320,RC,71100,CPT,,,Inpatient,,,239,,,,80,,191.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,185.7,percent of total billed charges,,,95,,227.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,227.05,
XR Ribs 3 Views Bilateral,3200284,CDM,320,RC,71110,CPT,,,Outpatient,,,287,,,,80,,229.6,percent of total billed charges,,,,50,67.37,fee schedule,,,77.7,,223,percent of total billed charges,,,95,,272.65,percent of total billed charges,,,60,,172.2,percent of total billed charges,,172.2,272.65,
XR Ribs 3 Views Bilateral,3200284,CDM,320,RC,71110,CPT,,,Inpatient,,,287,,,,80,,229.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,223,percent of total billed charges,,,95,,272.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,272.65,
XR Spine Cervical 2 or 3 Views,3200318,CDM,320,RC,72040,CPT,,,Outpatient,,,248,,,,80,,198.4,percent of total billed charges,,,,50,79.91,fee schedule,,,77.7,,192.7,percent of total billed charges,,,95,,235.6,percent of total billed charges,,,60,,148.8,percent of total billed charges,,148.8,235.6,
XR Spine Cervical 2 or 3 Views,3200318,CDM,320,RC,72040,CPT,,,Inpatient,,,248,,,,80,,198.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,192.7,percent of total billed charges,,,95,,235.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,235.6,
XR Spine Cervical Minimum 4 Views,3200326,CDM,320,RC,72050,CPT,,,Outpatient,,,347,,,,80,,277.6,percent of total billed charges,,,,50,115.22,fee schedule,,,77.7,,269.62,percent of total billed charges,,,95,,329.65,percent of total billed charges,,,60,,208.2,percent of total billed charges,,208.2,329.65,
XR Spine Cervical Minimum 4 Views,3200326,CDM,320,RC,72050,CPT,,,Inpatient,,,347,,,,80,,277.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,269.62,percent of total billed charges,,,95,,329.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,329.65,
XR Spine Cervical 6 or more views,3200334,CDM,320,RC,72052,CPT,,,Outpatient,,,633,,,,80,,506.4,percent of total billed charges,,,,50,135.67,fee schedule,,,77.7,,491.84,percent of total billed charges,,,95,,601.35,percent of total billed charges,,,60,,379.8,percent of total billed charges,,379.8,601.35,
XR Spine Cervical 6 or more views,3200334,CDM,320,RC,72052,CPT,,,Inpatient,,,633,,,,80,,506.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,491.84,percent of total billed charges,,,95,,601.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,601.35,
XR Spine Thoracic 3 Views,3200342,CDM,320,RC,72072,CPT,,,Outpatient,,,290,,,,80,,232,percent of total billed charges,,,,50,100.82,fee schedule,,,77.7,,225.33,percent of total billed charges,,,95,,275.5,percent of total billed charges,,,60,,174,percent of total billed charges,,174,275.5,
XR Spine Thoracic 3 Views,3200342,CDM,320,RC,72072,CPT,,,Inpatient,,,290,,,,80,,232,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,225.33,percent of total billed charges,,,95,,275.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,275.5,
XR Spine Lumbosacral 2 or 3 Views,3200359,CDM,320,RC,72100,CPT,,,Outpatient,,,262,,,,80,,209.6,percent of total billed charges,,,,50,87.35,fee schedule,,,77.7,,203.57,percent of total billed charges,,,95,,248.9,percent of total billed charges,,,60,,157.2,percent of total billed charges,,157.2,248.9,
XR Spine Lumbosacral 2 or 3 Views,3200359,CDM,320,RC,72100,CPT,,,Inpatient,,,262,,,,80,,209.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,203.57,percent of total billed charges,,,95,,248.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,248.9,
XR Spine Lumbosacral Minimum 4 Views,3200367,CDM,320,RC,72110,CPT,,,Outpatient,,,315,,,,80,,252,percent of total billed charges,,,,50,124.05,fee schedule,,,77.7,,244.76,percent of total billed charges,,,95,,299.25,percent of total billed charges,,,60,,189,percent of total billed charges,,189,299.25,
XR Spine Lumbosacral Minimum 4 Views,3200367,CDM,320,RC,72110,CPT,,,Inpatient,,,315,,,,80,,252,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,244.76,percent of total billed charges,,,95,,299.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,299.25,
XR Pelvis 1 or 2 Views,3200383,CDM,320,RC,72170,CPT,,,Outpatient,,,202,,,,80,,161.6,percent of total billed charges,,,,50,63.19,fee schedule,,,77.7,,156.95,percent of total billed charges,,,95,,191.9,percent of total billed charges,,,60,,121.2,percent of total billed charges,,121.2,191.9,
XR Pelvis 1 or 2 Views,3200383,CDM,320,RC,72170,CPT,,,Inpatient,,,202,,,,80,,161.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,156.95,percent of total billed charges,,,95,,191.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,191.9,
XR Pelvis Complete Minimum 3 Views,3200409,CDM,320,RC,72190,CPT,,,Outpatient,,,200,,,,80,,160,percent of total billed charges,,,,50,67.83,fee schedule,,,77.7,,155.4,percent of total billed charges,,,95,,190,percent of total billed charges,,,60,,120,percent of total billed charges,,120,190,
XR Pelvis Complete Minimum 3 Views,3200409,CDM,320,RC,72190,CPT,,,Inpatient,,,200,,,,80,,160,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,155.4,percent of total billed charges,,,95,,190,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,190,
XR Sacrum/Coccyx Minimum 2 Views,3200425,CDM,320,RC,72220,CPT,,,Outpatient,,,207,,,,80,,165.6,percent of total billed charges,,,,50,71.55,fee schedule,,,77.7,,160.84,percent of total billed charges,,,95,,196.65,percent of total billed charges,,,60,,124.2,percent of total billed charges,,124.2,196.65,
XR Sacrum/Coccyx Minimum 2 Views,3200425,CDM,320,RC,72220,CPT,,,Inpatient,,,207,,,,80,,165.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,160.84,percent of total billed charges,,,95,,196.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,196.65,
XR Clavicle Left,3200441,CDM,320,RC,73000,CPT,,,Outpatient,,,217,,LT,,80,,173.6,percent of total billed charges,,,,50,57.15,fee schedule,,,77.7,,168.61,percent of total billed charges,,,95,,206.15,percent of total billed charges,,,60,,130.2,percent of total billed charges,,130.2,206.15,
XR Clavicle Right,3200441,CDM,320,RC,73000,CPT,,,Outpatient,,,217,,RT,,80,,173.6,percent of total billed charges,,,,50,57.15,fee schedule,,,77.7,,168.61,percent of total billed charges,,,95,,206.15,percent of total billed charges,,,60,,130.2,percent of total billed charges,,130.2,206.15,
XR Clavicle Left,3200441,CDM,320,RC,73000,CPT,,,Inpatient,,,217,,LT,,80,,173.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,168.61,percent of total billed charges,,,95,,206.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,206.15,
XR Clavicle Right,3200441,CDM,320,RC,73000,CPT,,,Inpatient,,,217,,RT,,80,,173.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,168.61,percent of total billed charges,,,95,,206.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,206.15,
XR Shoulder 1 View Left,3200466,CDM,320,RC,73020,CPT,,,Outpatient,,,144,,LT,,80,,115.2,percent of total billed charges,,,,50,52.97,fee schedule,,,77.7,,111.89,percent of total billed charges,,,95,,136.8,percent of total billed charges,,,60,,86.4,percent of total billed charges,,86.4,136.8,
XR Shoulder 1 View Right,3200466,CDM,320,RC,73020,CPT,,,Outpatient,,,144,,RT,,80,,115.2,percent of total billed charges,,,,50,52.97,fee schedule,,,77.7,,111.89,percent of total billed charges,,,95,,136.8,percent of total billed charges,,,60,,86.4,percent of total billed charges,,86.4,136.8,
XR Shoulder 1 View Left,3200466,CDM,320,RC,73020,CPT,,,Inpatient,,,144,,LT,,80,,115.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,111.89,percent of total billed charges,,,95,,136.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,136.8,
XR Shoulder 1 View Right,3200466,CDM,320,RC,73020,CPT,,,Inpatient,,,144,,RT,,80,,115.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,111.89,percent of total billed charges,,,95,,136.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,136.8,
XR Shoulder Complete Left,3200474,CDM,320,RC,73030,CPT,,,Outpatient,,,255,,LT,,80,,204,percent of total billed charges,,,,50,70.16,fee schedule,,,77.7,,198.14,percent of total billed charges,,,95,,242.25,percent of total billed charges,,,60,,153,percent of total billed charges,,153,242.25,
XR Shoulder Complete Right,3200474,CDM,320,RC,73030,CPT,,,Outpatient,,,255,,RT,,80,,204,percent of total billed charges,,,,50,70.16,fee schedule,,,77.7,,198.14,percent of total billed charges,,,95,,242.25,percent of total billed charges,,,60,,153,percent of total billed charges,,153,242.25,
XR Shoulder Complete Left,3200474,CDM,320,RC,73030,CPT,,,Inpatient,,,255,,LT,,80,,204,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,198.14,percent of total billed charges,,,95,,242.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,242.25,
XR Shoulder Complete Right,3200474,CDM,320,RC,73030,CPT,,,Inpatient,,,255,,RT,,80,,204,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,198.14,percent of total billed charges,,,95,,242.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,242.25,
XR Humerus Left,3200490,CDM,320,RC,73060,CPT,,,Outpatient,,,199,,LT,,80,,159.2,percent of total billed charges,,,,50,68.76,fee schedule,,,77.7,,154.62,percent of total billed charges,,,95,,189.05,percent of total billed charges,,,60,,119.4,percent of total billed charges,,119.4,189.05,
XR Humerus Right,3200490,CDM,320,RC,73060,CPT,,,Outpatient,,,199,,RT,,80,,159.2,percent of total billed charges,,,,50,68.76,fee schedule,,,77.7,,154.62,percent of total billed charges,,,95,,189.05,percent of total billed charges,,,60,,119.4,percent of total billed charges,,119.4,189.05,
XR Humerus Left,3200490,CDM,320,RC,73060,CPT,,,Inpatient,,,199,,LT,,80,,159.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,154.62,percent of total billed charges,,,95,,189.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,189.05,
XR Humerus Right,3200490,CDM,320,RC,73060,CPT,,,Inpatient,,,199,,RT,,80,,159.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,154.62,percent of total billed charges,,,95,,189.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,189.05,
XR Elbow 2 Views Left,3200508,CDM,320,RC,73070,CPT,,,Outpatient,,,193,,LT,,80,,154.4,percent of total billed charges,,,,50,56.68,fee schedule,,,77.7,,149.96,percent of total billed charges,,,95,,183.35,percent of total billed charges,,,60,,115.8,percent of total billed charges,,115.8,183.35,
XR Elbow 2 Views Right,3200508,CDM,320,RC,73070,CPT,,,Outpatient,,,193,,RT,,80,,154.4,percent of total billed charges,,,,50,56.68,fee schedule,,,77.7,,149.96,percent of total billed charges,,,95,,183.35,percent of total billed charges,,,60,,115.8,percent of total billed charges,,115.8,183.35,
XR Elbow 2 Views Left,3200508,CDM,320,RC,73070,CPT,,,Inpatient,,,193,,LT,,80,,154.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,149.96,percent of total billed charges,,,95,,183.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,183.35,
XR Elbow 2 Views Right,3200508,CDM,320,RC,73070,CPT,,,Inpatient,,,193,,RT,,80,,154.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,149.96,percent of total billed charges,,,95,,183.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,183.35,
XR Elbow Complete Left,3200516,CDM,320,RC,73080,CPT,,,Outpatient,,,238,,LT,,80,,190.4,percent of total billed charges,,,,50,75.73,fee schedule,,,77.7,,184.93,percent of total billed charges,,,95,,226.1,percent of total billed charges,,,60,,142.8,percent of total billed charges,,142.8,226.1,
XR Elbow Complete Right,3200516,CDM,320,RC,73080,CPT,,,Outpatient,,,238,,RT,,80,,190.4,percent of total billed charges,,,,50,75.73,fee schedule,,,77.7,,184.93,percent of total billed charges,,,95,,226.1,percent of total billed charges,,,60,,142.8,percent of total billed charges,,142.8,226.1,
XR Elbow Complete Left,3200516,CDM,320,RC,73080,CPT,,,Inpatient,,,238,,LT,,80,,190.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,184.93,percent of total billed charges,,,95,,226.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,226.1,
XR Elbow Complete Right,3200516,CDM,320,RC,73080,CPT,,,Inpatient,,,238,,RT,,80,,190.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,184.93,percent of total billed charges,,,95,,226.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,226.1,
XR Forearm 2 Views Left,3200524,CDM,320,RC,73090,CPT,,,Outpatient,,,200,,LT,,80,,160,percent of total billed charges,,,,50,62.26,fee schedule,,,77.7,,155.4,percent of total billed charges,,,95,,190,percent of total billed charges,,,60,,120,percent of total billed charges,,120,190,
XR Forearm 2 Views Right,3200524,CDM,320,RC,73090,CPT,,,Outpatient,,,200,,RT,,80,,160,percent of total billed charges,,,,50,62.26,fee schedule,,,77.7,,155.4,percent of total billed charges,,,95,,190,percent of total billed charges,,,60,,120,percent of total billed charges,,120,190,
XR Forearm 2 Views Left,3200524,CDM,320,RC,73090,CPT,,,Inpatient,,,200,,LT,,80,,160,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,155.4,percent of total billed charges,,,95,,190,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,190,
XR Forearm 2 Views Right,3200524,CDM,320,RC,73090,CPT,,,Inpatient,,,200,,RT,,80,,160,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,155.4,percent of total billed charges,,,95,,190,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,190,
XR Wrist 2 Views Left,3200532,CDM,320,RC,73100,CPT,,,Outpatient,,,196,,LT,,80,,156.8,percent of total billed charges,,,,50,48.32,fee schedule,,,77.7,,152.29,percent of total billed charges,,,95,,186.2,percent of total billed charges,,,60,,117.6,percent of total billed charges,,117.6,186.2,
XR Wrist 2 Views Right,3200532,CDM,320,RC,73100,CPT,,,Outpatient,,,196,,RT,,80,,156.8,percent of total billed charges,,,,50,48.32,fee schedule,,,77.7,,152.29,percent of total billed charges,,,95,,186.2,percent of total billed charges,,,60,,117.6,percent of total billed charges,,117.6,186.2,
XR Wrist 2 Views Left,3200532,CDM,320,RC,73100,CPT,,,Inpatient,,,196,,LT,,80,,156.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,152.29,percent of total billed charges,,,95,,186.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,186.2,
XR Wrist 2 Views Right,3200532,CDM,320,RC,73100,CPT,,,Inpatient,,,196,,RT,,80,,156.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,152.29,percent of total billed charges,,,95,,186.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,186.2,
XR Wrist Complete Left,3200540,CDM,320,RC,73110,CPT,,,Outpatient,,,230,,LT,,80,,184,percent of total billed charges,,,,50,71.55,fee schedule,,,77.7,,178.71,percent of total billed charges,,,95,,218.5,percent of total billed charges,,,60,,138,percent of total billed charges,,138,218.5,
XR Wrist Complete Right,3200540,CDM,320,RC,73110,CPT,,,Outpatient,,,230,,RT,,80,,184,percent of total billed charges,,,,50,71.55,fee schedule,,,77.7,,178.71,percent of total billed charges,,,95,,218.5,percent of total billed charges,,,60,,138,percent of total billed charges,,138,218.5,
XR Wrist Complete Left,3200540,CDM,320,RC,73110,CPT,,,Inpatient,,,230,,LT,,80,,184,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,178.71,percent of total billed charges,,,95,,218.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,218.5,
XR Wrist Complete Right,3200540,CDM,320,RC,73110,CPT,,,Inpatient,,,230,,RT,,80,,184,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,178.71,percent of total billed charges,,,95,,218.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,218.5,
XR Hand Complete Left,3200557,CDM,320,RC,73130,CPT,,,Outpatient,,,215,,LT,,80,,172,percent of total billed charges,,,,50,68.3,fee schedule,,,77.7,,167.06,percent of total billed charges,,,95,,204.25,percent of total billed charges,,,60,,129,percent of total billed charges,,129,204.25,
XR Hand Complete Right,3200557,CDM,320,RC,73130,CPT,,,Outpatient,,,215,,RT,,80,,172,percent of total billed charges,,,,50,68.3,fee schedule,,,77.7,,167.06,percent of total billed charges,,,95,,204.25,percent of total billed charges,,,60,,129,percent of total billed charges,,129,204.25,
XR Hand Complete Left,3200557,CDM,320,RC,73130,CPT,,,Inpatient,,,215,,LT,,80,,172,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,167.06,percent of total billed charges,,,95,,204.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,204.25,
XR Hand Complete Right,3200557,CDM,320,RC,73130,CPT,,,Inpatient,,,215,,RT,,80,,172,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,167.06,percent of total billed charges,,,95,,204.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,204.25,
XR Finger 2nd Digit Left,3200565,CDM,320,RC,73140,CPT,,,Outpatient,,,140,,LT,,80,,112,percent of total billed charges,,,,50,52.97,fee schedule,,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,60,,84,percent of total billed charges,,84,133,
XR Finger 2nd Digit Right,3200565,CDM,320,RC,73140,CPT,,,Outpatient,,,140,,RT,,80,,112,percent of total billed charges,,,,50,52.97,fee schedule,,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,60,,84,percent of total billed charges,,84,133,
XR Finger 3rd Digit Left,3200565,CDM,320,RC,73140,CPT,,,Outpatient,,,140,,LT,,80,,112,percent of total billed charges,,,,50,52.97,fee schedule,,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,60,,84,percent of total billed charges,,84,133,
XR Finger 3rd Digit Right,3200565,CDM,320,RC,73140,CPT,,,Outpatient,,,140,,RT,,80,,112,percent of total billed charges,,,,50,52.97,fee schedule,,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,60,,84,percent of total billed charges,,84,133,
XR Finger 4th Digit Left,3200565,CDM,320,RC,73140,CPT,,,Outpatient,,,140,,LT,,80,,112,percent of total billed charges,,,,50,52.97,fee schedule,,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,60,,84,percent of total billed charges,,84,133,
XR Finger 4th Digit Right,3200565,CDM,320,RC,73140,CPT,,,Outpatient,,,140,,RT,,80,,112,percent of total billed charges,,,,50,52.97,fee schedule,,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,60,,84,percent of total billed charges,,84,133,
XR Finger 5th Digit Left,3200565,CDM,320,RC,73140,CPT,,,Outpatient,,,140,,LT,,80,,112,percent of total billed charges,,,,50,52.97,fee schedule,,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,60,,84,percent of total billed charges,,84,133,
XR Finger 5th Digit Right,3200565,CDM,320,RC,73140,CPT,,,Outpatient,,,140,,RT,,80,,112,percent of total billed charges,,,,50,52.97,fee schedule,,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,60,,84,percent of total billed charges,,84,133,
XR Finger Thumb Left,3200565,CDM,320,RC,73140,CPT,,,Outpatient,,,140,,LT,,80,,112,percent of total billed charges,,,,50,52.97,fee schedule,,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,60,,84,percent of total billed charges,,84,133,
XR Finger Thumb Right,3200565,CDM,320,RC,73140,CPT,,,Outpatient,,,140,,RT,,80,,112,percent of total billed charges,,,,50,52.97,fee schedule,,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,60,,84,percent of total billed charges,,84,133,
XR Finger 2nd Digit Left,3200565,CDM,320,RC,73140,CPT,,,Inpatient,,,140,,LT,,80,,112,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,133,
XR Finger 2nd Digit Right,3200565,CDM,320,RC,73140,CPT,,,Inpatient,,,140,,RT,,80,,112,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,133,
XR Finger 3rd Digit Left,3200565,CDM,320,RC,73140,CPT,,,Inpatient,,,140,,LT,,80,,112,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,133,
XR Finger 3rd Digit Right,3200565,CDM,320,RC,73140,CPT,,,Inpatient,,,140,,RT,,80,,112,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,133,
XR Finger 4th Digit Left,3200565,CDM,320,RC,73140,CPT,,,Inpatient,,,140,,LT,,80,,112,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,133,
XR Finger 4th Digit Right,3200565,CDM,320,RC,73140,CPT,,,Inpatient,,,140,,RT,,80,,112,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,133,
XR Finger 5th Digit Left,3200565,CDM,320,RC,73140,CPT,,,Inpatient,,,140,,LT,,80,,112,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,133,
XR Finger 5th Digit Right,3200565,CDM,320,RC,73140,CPT,,,Inpatient,,,140,,RT,,80,,112,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,133,
XR Finger Thumb Left,3200565,CDM,320,RC,73140,CPT,,,Inpatient,,,140,,LT,,80,,112,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,133,
XR Finger Thumb Right,3200565,CDM,320,RC,73140,CPT,,,Inpatient,,,140,,RT,,80,,112,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,133,
XR Knee 1 or 2 Views Left,3200615,CDM,320,RC,73560,CPT,,,Outpatient,,,190,,LT,,80,,152,percent of total billed charges,,,,50,53.9,fee schedule,,,77.7,,147.63,percent of total billed charges,,,95,,180.5,percent of total billed charges,,,60,,114,percent of total billed charges,,114,180.5,
XR Knee 1 or 2 Views Right,3200615,CDM,320,RC,73560,CPT,,,Outpatient,,,190,,RT,,80,,152,percent of total billed charges,,,,50,53.9,fee schedule,,,77.7,,147.63,percent of total billed charges,,,95,,180.5,percent of total billed charges,,,60,,114,percent of total billed charges,,114,180.5,
XR Knee 1 or 2 Views Left,3200615,CDM,320,RC,73560,CPT,,,Inpatient,,,190,,LT,,80,,152,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,147.63,percent of total billed charges,,,95,,180.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,180.5,
XR Knee 1 or 2 Views Right,3200615,CDM,320,RC,73560,CPT,,,Inpatient,,,190,,RT,,80,,152,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,147.63,percent of total billed charges,,,95,,180.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,180.5,
XR Tibia/Fibula Left,3200631,CDM,320,RC,73590,CPT,,,Outpatient,,,219,,LT,,80,,175.2,percent of total billed charges,,,,50,71.09,fee schedule,,,77.7,,170.16,percent of total billed charges,,,95,,208.05,percent of total billed charges,,,60,,131.4,percent of total billed charges,,131.4,208.05,
XR Tibia/Fibula Right,3200631,CDM,320,RC,73590,CPT,,,Outpatient,,,219,,RT,,80,,175.2,percent of total billed charges,,,,50,71.09,fee schedule,,,77.7,,170.16,percent of total billed charges,,,95,,208.05,percent of total billed charges,,,60,,131.4,percent of total billed charges,,131.4,208.05,
XR Tibia/Fibula Left,3200631,CDM,320,RC,73590,CPT,,,Inpatient,,,219,,LT,,80,,175.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,170.16,percent of total billed charges,,,95,,208.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,208.05,
XR Tibia/Fibula Right,3200631,CDM,320,RC,73590,CPT,,,Inpatient,,,219,,RT,,80,,175.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,170.16,percent of total billed charges,,,95,,208.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,208.05,
XR Ankle 2 Views Left,3200649,CDM,320,RC,73600,CPT,,,Outpatient,,,194,,LT,,80,,155.2,percent of total billed charges,,,,50,52.04,fee schedule,,,77.7,,150.74,percent of total billed charges,,,95,,184.3,percent of total billed charges,,,60,,116.4,percent of total billed charges,,116.4,184.3,
XR Ankle 2 Views Right,3200649,CDM,320,RC,73600,CPT,,,Outpatient,,,194,,RT,,80,,155.2,percent of total billed charges,,,,50,52.04,fee schedule,,,77.7,,150.74,percent of total billed charges,,,95,,184.3,percent of total billed charges,,,60,,116.4,percent of total billed charges,,116.4,184.3,
XR Ankle 2 Views Left,3200649,CDM,320,RC,73600,CPT,,,Inpatient,,,194,,LT,,80,,155.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,150.74,percent of total billed charges,,,95,,184.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,184.3,
XR Ankle 2 Views Right,3200649,CDM,320,RC,73600,CPT,,,Inpatient,,,194,,RT,,80,,155.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,150.74,percent of total billed charges,,,95,,184.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,184.3,
XR Ankle Complete Left,3200656,CDM,320,RC,73610,CPT,,,Outpatient,,,220,,LT,,80,,176,percent of total billed charges,,,,50,69.69,fee schedule,,,77.7,,170.94,percent of total billed charges,,,95,,209,percent of total billed charges,,,60,,132,percent of total billed charges,,132,209,
XR Ankle Complete Right,3200656,CDM,320,RC,73610,CPT,,,Outpatient,,,220,,RT,,80,,176,percent of total billed charges,,,,50,69.69,fee schedule,,,77.7,,170.94,percent of total billed charges,,,95,,209,percent of total billed charges,,,60,,132,percent of total billed charges,,132,209,
XR Ankle Complete Left,3200656,CDM,320,RC,73610,CPT,,,Inpatient,,,220,,LT,,80,,176,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,170.94,percent of total billed charges,,,95,,209,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,209,
XR Ankle Complete Right,3200656,CDM,320,RC,73610,CPT,,,Inpatient,,,220,,RT,,80,,176,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,170.94,percent of total billed charges,,,95,,209,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,209,
XR Foot 2 Views Left,3200664,CDM,320,RC,73620,CPT,,,Outpatient,,,180,,LT,,80,,144,percent of total billed charges,,,,50,47.39,fee schedule,,,77.7,,139.86,percent of total billed charges,,,95,,171,percent of total billed charges,,,60,,108,percent of total billed charges,,108,171,
XR Foot 2 Views Right,3200664,CDM,320,RC,73620,CPT,,,Outpatient,,,180,,RT,,80,,144,percent of total billed charges,,,,50,47.39,fee schedule,,,77.7,,139.86,percent of total billed charges,,,95,,171,percent of total billed charges,,,60,,108,percent of total billed charges,,108,171,
XR Foot 2 Views Left,3200664,CDM,320,RC,73620,CPT,,,Inpatient,,,180,,LT,,80,,144,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,139.86,percent of total billed charges,,,95,,171,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,171,
XR Foot 2 Views Right,3200664,CDM,320,RC,73620,CPT,,,Inpatient,,,180,,RT,,80,,144,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,139.86,percent of total billed charges,,,95,,171,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,171,
XR Foot Complete Left,3200672,CDM,320,RC,73630,CPT,,,Outpatient,,,233,,LT,,80,,186.4,percent of total billed charges,,,,50,67.37,fee schedule,,,77.7,,181.04,percent of total billed charges,,,95,,221.35,percent of total billed charges,,,60,,139.8,percent of total billed charges,,139.8,221.35,
XR Foot Complete Right,3200672,CDM,320,RC,73630,CPT,,,Outpatient,,,233,,RT,,80,,186.4,percent of total billed charges,,,,50,67.37,fee schedule,,,77.7,,181.04,percent of total billed charges,,,95,,221.35,percent of total billed charges,,,60,,139.8,percent of total billed charges,,139.8,221.35,
XR Foot Complete Left,3200672,CDM,320,RC,73630,CPT,,,Inpatient,,,233,,LT,,80,,186.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,181.04,percent of total billed charges,,,95,,221.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,221.35,
XR Foot Complete Right,3200672,CDM,320,RC,73630,CPT,,,Inpatient,,,233,,RT,,80,,186.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,181.04,percent of total billed charges,,,95,,221.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,221.35,
XR Toes 2nd Digit Left,3200698,CDM,320,RC,73660,CPT,,,Outpatient,,,140,,LT,,80,,112,percent of total billed charges,,,,50,53.9,fee schedule,,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,60,,84,percent of total billed charges,,84,133,
XR Toes 2nd Digit Right,3200698,CDM,320,RC,73660,CPT,,,Outpatient,,,140,,RT,,80,,112,percent of total billed charges,,,,50,53.9,fee schedule,,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,60,,84,percent of total billed charges,,84,133,
XR Toes 3rd Digit Left,3200698,CDM,320,RC,73660,CPT,,,Outpatient,,,140,,LT,,80,,112,percent of total billed charges,,,,50,53.9,fee schedule,,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,60,,84,percent of total billed charges,,84,133,
XR Toes 3rd Digit Right,3200698,CDM,320,RC,73660,CPT,,,Outpatient,,,140,,RT,,80,,112,percent of total billed charges,,,,50,53.9,fee schedule,,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,60,,84,percent of total billed charges,,84,133,
XR Toes 4th Digit Left,3200698,CDM,320,RC,73660,CPT,,,Outpatient,,,140,,LT,,80,,112,percent of total billed charges,,,,50,53.9,fee schedule,,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,60,,84,percent of total billed charges,,84,133,
XR Toes 4th Digit Right,3200698,CDM,320,RC,73660,CPT,,,Outpatient,,,140,,RT,,80,,112,percent of total billed charges,,,,50,53.9,fee schedule,,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,60,,84,percent of total billed charges,,84,133,
XR Toes 5th Digit Left,3200698,CDM,320,RC,73660,CPT,,,Outpatient,,,140,,LT,,80,,112,percent of total billed charges,,,,50,53.9,fee schedule,,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,60,,84,percent of total billed charges,,84,133,
XR Toes 5th Digit Right,3200698,CDM,320,RC,73660,CPT,,,Outpatient,,,140,,RT,,80,,112,percent of total billed charges,,,,50,53.9,fee schedule,,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,60,,84,percent of total billed charges,,84,133,
XR Toes Great Left,3200698,CDM,320,RC,73660,CPT,,,Outpatient,,,140,,LT,,80,,112,percent of total billed charges,,,,50,53.9,fee schedule,,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,60,,84,percent of total billed charges,,84,133,
XR Toes Great Right,3200698,CDM,320,RC,73660,CPT,,,Outpatient,,,140,,RT,,80,,112,percent of total billed charges,,,,50,53.9,fee schedule,,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,60,,84,percent of total billed charges,,84,133,
XR Toes 2nd Digit Left,3200698,CDM,320,RC,73660,CPT,,,Inpatient,,,140,,LT,,80,,112,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,133,
XR Toes 2nd Digit Right,3200698,CDM,320,RC,73660,CPT,,,Inpatient,,,140,,RT,,80,,112,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,133,
XR Toes 3rd Digit Left,3200698,CDM,320,RC,73660,CPT,,,Inpatient,,,140,,LT,,80,,112,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,133,
XR Toes 3rd Digit Right,3200698,CDM,320,RC,73660,CPT,,,Inpatient,,,140,,RT,,80,,112,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,133,
XR Toes 4th Digit Left,3200698,CDM,320,RC,73660,CPT,,,Inpatient,,,140,,LT,,80,,112,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,133,
XR Toes 4th Digit Right,3200698,CDM,320,RC,73660,CPT,,,Inpatient,,,140,,RT,,80,,112,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,133,
XR Toes 5th Digit Left,3200698,CDM,320,RC,73660,CPT,,,Inpatient,,,140,,LT,,80,,112,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,133,
XR Toes 5th Digit Right,3200698,CDM,320,RC,73660,CPT,,,Inpatient,,,140,,RT,,80,,112,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,133,
XR Toes Great Left,3200698,CDM,320,RC,73660,CPT,,,Inpatient,,,140,,LT,,80,,112,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,133,
XR Toes Great Right,3200698,CDM,320,RC,73660,CPT,,,Inpatient,,,140,,RT,,80,,112,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,133,
XR Abdomen Series w/ Chest 1 View,3200730,CDM,320,RC,74022,CPT,,,Outpatient,,,390,,,,80,,312,percent of total billed charges,,,,50,131.95,fee schedule,,,77.7,,303.03,percent of total billed charges,,,95,,370.5,percent of total billed charges,,,60,,234,percent of total billed charges,,234,370.5,
XR Abdomen Series w/ Chest 1 View,3200730,CDM,320,RC,74022,CPT,,,Inpatient,,,390,,,,80,,312,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,303.03,percent of total billed charges,,,95,,370.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,370.5,
XR Ribs Min 3 Views Left w/ PA Chest,3201092,CDM,320,RC,71101,CPT,,,Outpatient,,,348,,,,80,,278.4,percent of total billed charges,,,,50,99.89,fee schedule,,,77.7,,270.4,percent of total billed charges,,,95,,330.6,percent of total billed charges,,,60,,208.8,percent of total billed charges,,208.8,330.6,
XR Ribs Min 3 Views Right w/ PA Chest,3201092,CDM,320,RC,71101,CPT,,,Outpatient,,,348,,,,80,,278.4,percent of total billed charges,,,,50,99.89,fee schedule,,,77.7,,270.4,percent of total billed charges,,,95,,330.6,percent of total billed charges,,,60,,208.8,percent of total billed charges,,208.8,330.6,
XR Ribs Min 3 Views Left w/ PA Chest,3201092,CDM,320,RC,71101,CPT,,,Inpatient,,,348,,,,80,,278.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,270.4,percent of total billed charges,,,95,,330.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,330.6,
XR Ribs Min 3 Views Right w/ PA Chest,3201092,CDM,320,RC,71101,CPT,,,Inpatient,,,348,,,,80,,278.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,270.4,percent of total billed charges,,,95,,330.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,330.6,
XR Ribs Min 4 Views PA Chest Bilateral,3201100,CDM,320,RC,71111,CPT,,,Outpatient,,,372,,,,80,,297.6,percent of total billed charges,,,,50,122.66,fee schedule,,,77.7,,289.04,percent of total billed charges,,,95,,353.4,percent of total billed charges,,,60,,223.2,percent of total billed charges,,223.2,353.4,
XR Ribs Min 4 Views PA Chest Bilateral,3201100,CDM,320,RC,71111,CPT,,,Inpatient,,,372,,,,80,,297.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,289.04,percent of total billed charges,,,95,,353.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,353.4,
XR Spine Thoracic 2 Views,3201134,CDM,320,RC,72070,CPT,,,Outpatient,,,234,,,,80,,187.2,percent of total billed charges,,,,50,66.9,fee schedule,,,77.7,,181.82,percent of total billed charges,,,95,,222.3,percent of total billed charges,,,60,,140.4,percent of total billed charges,,140.4,222.3,
XR Spine Thoracic 2 Views,3201134,CDM,320,RC,72070,CPT,,,Inpatient,,,234,,,,80,,187.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,181.82,percent of total billed charges,,,95,,222.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,222.3,
XR Knee 4 Views w/ Patella Left,3201217,CDM,320,RC,73564,CPT,,,Outpatient,,,280,,LT,,80,,224,percent of total billed charges,,,,50,108.25,fee schedule,,,77.7,,217.56,percent of total billed charges,,,95,,266,percent of total billed charges,,,60,,168,percent of total billed charges,,168,266,
XR Knee 4 Views w/ Patella Right,3201217,CDM,320,RC,73564,CPT,,,Outpatient,,,280,,RT,,80,,224,percent of total billed charges,,,,50,108.25,fee schedule,,,77.7,,217.56,percent of total billed charges,,,95,,266,percent of total billed charges,,,60,,168,percent of total billed charges,,168,266,
XR Knee 4 Views w/ Patella Left,3201217,CDM,320,RC,73564,CPT,,,Inpatient,,,280,,LT,,80,,224,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,217.56,percent of total billed charges,,,95,,266,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,266,
XR Knee 4 Views w/ Patella Right,3201217,CDM,320,RC,73564,CPT,,,Inpatient,,,280,,RT,,80,,224,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,217.56,percent of total billed charges,,,95,,266,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,266,
XR Knee Standing AP Bilateral,3201340,CDM,320,RC,73565,CPT,,,Outpatient,,,161,,,,80,,128.8,percent of total billed charges,,,,50,54.83,fee schedule,,,77.7,,125.1,percent of total billed charges,,,95,,152.95,percent of total billed charges,,,60,,96.6,percent of total billed charges,,96.6,152.95,
XR Knee Standing AP Bilateral,3201340,CDM,320,RC,73565,CPT,,,Inpatient,,,161,,,,80,,128.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,125.1,percent of total billed charges,,,95,,152.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,152.95,
XR Hand 2 Views Left,3201365,CDM,320,RC,73120,CPT,,,Outpatient,,,234,,LT,,80,,187.2,percent of total billed charges,,,,50,52.04,fee schedule,,,77.7,,181.82,percent of total billed charges,,,95,,222.3,percent of total billed charges,,,60,,140.4,percent of total billed charges,,140.4,222.3,
XR Hand 2 Views Right,3201365,CDM,320,RC,73120,CPT,,,Outpatient,,,234,,RT,,80,,187.2,percent of total billed charges,,,,50,52.04,fee schedule,,,77.7,,181.82,percent of total billed charges,,,95,,222.3,percent of total billed charges,,,60,,140.4,percent of total billed charges,,140.4,222.3,
XR Hand 2 Views Left,3201365,CDM,320,RC,73120,CPT,,,Inpatient,,,234,,LT,,80,,187.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,181.82,percent of total billed charges,,,95,,222.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,222.3,
XR Hand 2 Views Right,3201365,CDM,320,RC,73120,CPT,,,Inpatient,,,234,,RT,,80,,187.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,181.82,percent of total billed charges,,,95,,222.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,222.3,
XR Swallowing Function w/ Video,3201985,CDM,320,RC,74230,CPT,,,Outpatient,,,546,,,,80,,436.8,percent of total billed charges,,,,50,156.11,fee schedule,,,77.7,,424.24,percent of total billed charges,,,95,,518.7,percent of total billed charges,,,60,,327.6,percent of total billed charges,,327.6,518.7,
XR Swallowing Function w/ Video,3201985,CDM,320,RC,74230,CPT,,,Inpatient,,,546,,,,80,,436.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,424.24,percent of total billed charges,,,95,,518.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,518.7,
XR Knee 3 Views Left,3203155,CDM,320,RC,73562,CPT,,,Outpatient,,,240,,LT,,80,,192,percent of total billed charges,,,,50,74.8,fee schedule,,,77.7,,186.48,percent of total billed charges,,,95,,228,percent of total billed charges,,,60,,144,percent of total billed charges,,144,228,
XR Knee 3 Views Right,3203155,CDM,320,RC,73562,CPT,,,Outpatient,,,240,,RT,,80,,192,percent of total billed charges,,,,50,74.8,fee schedule,,,77.7,,186.48,percent of total billed charges,,,95,,228,percent of total billed charges,,,60,,144,percent of total billed charges,,144,228,
XR Knee 3 Views Left,3203155,CDM,320,RC,73562,CPT,,,Inpatient,,,240,,LT,,80,,192,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,186.48,percent of total billed charges,,,95,,228,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,228,
XR Knee 3 Views Right,3203155,CDM,320,RC,73562,CPT,,,Inpatient,,,240,,RT,,80,,192,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,186.48,percent of total billed charges,,,95,,228,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,228,
XR Femur 1 View Lt,3203189,CDM,320,RC,73551,CPT,,,Outpatient,,,241,,LT,,80,,192.8,percent of total billed charges,,,,85,204.85,percent of total billed charges,,,77.7,,187.26,percent of total billed charges,,,95,,228.95,percent of total billed charges,,,60,,144.6,percent of total billed charges,,144.6,228.95,
XR Femur 1 View Lt,3203189,CDM,320,RC,73551,CPT,,,Inpatient,,,241,,LT,,80,,192.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,187.26,percent of total billed charges,,,95,,228.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,228.95,
XR Spine Entire 2-3 Views,3203247,CDM,320,RC,72082,CPT,,,Outpatient,,,182,,,,80,,145.6,percent of total billed charges,,,,85,154.7,percent of total billed charges,,,77.7,,141.41,percent of total billed charges,,,95,,172.9,percent of total billed charges,,,60,,109.2,percent of total billed charges,,109.2,172.9,
XR Spine Entire 2-3 Views,3203247,CDM,320,RC,72082,CPT,,,Inpatient,,,182,,,,80,,145.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,141.41,percent of total billed charges,,,95,,172.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,172.9,
XR Hip 1 View Left,3203270,CDM,320,RC,73501,CPT,,,Outpatient,,,177,,LT,,80,,141.6,percent of total billed charges,,,,50,71.01,fee schedule,,,77.7,,137.53,percent of total billed charges,,,95,,168.15,percent of total billed charges,,,60,,106.2,percent of total billed charges,,106.2,168.15,
XR Hip 1 View Right,3203270,CDM,320,RC,73501,CPT,,,Outpatient,,,177,,RT,,80,,141.6,percent of total billed charges,,,,50,71.01,fee schedule,,,77.7,,137.53,percent of total billed charges,,,95,,168.15,percent of total billed charges,,,60,,106.2,percent of total billed charges,,106.2,168.15,
XR Hip 1 View Left,3203270,CDM,320,RC,73501,CPT,,,Inpatient,,,177,,LT,,80,,141.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,137.53,percent of total billed charges,,,95,,168.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,168.15,
XR Hip 1 View Right,3203270,CDM,320,RC,73501,CPT,,,Inpatient,,,177,,RT,,80,,141.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,137.53,percent of total billed charges,,,95,,168.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,168.15,
XR Hip 2-3 View - Left,3203288,CDM,320,RC,73502,CPT,,,Outpatient,,,230,,LT,,80,,184,percent of total billed charges,,,,50,86.63,fee schedule,,,77.7,,178.71,percent of total billed charges,,,95,,218.5,percent of total billed charges,,,60,,138,percent of total billed charges,,138,218.5,
XR Hip 2-3 View - Right,3203288,CDM,320,RC,73502,CPT,,,Outpatient,,,230,,RT,,80,,184,percent of total billed charges,,,,50,86.63,fee schedule,,,77.7,,178.71,percent of total billed charges,,,95,,218.5,percent of total billed charges,,,60,,138,percent of total billed charges,,138,218.5,
XR Hip 2-3 View - Left,3203288,CDM,320,RC,73502,CPT,,,Inpatient,,,230,,LT,,80,,184,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,178.71,percent of total billed charges,,,95,,218.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,218.5,
XR Hip 2-3 View - Right,3203288,CDM,320,RC,73502,CPT,,,Inpatient,,,230,,RT,,80,,184,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,178.71,percent of total billed charges,,,95,,218.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,218.5,
XR Hip Min 4 Views Lt w/ Pelvis,3203296,CDM,320,RC,73503,CPT,,,Outpatient,,,265,,LT,,80,,212,percent of total billed charges,,,,50,106.51,fee schedule,,,77.7,,205.91,percent of total billed charges,,,95,,251.75,percent of total billed charges,,,60,,159,percent of total billed charges,,159,251.75,
XR Hip Min 4 Views Rt w/ Pelvis,3203296,CDM,320,RC,73503,CPT,,,Outpatient,,,265,,RT,,80,,212,percent of total billed charges,,,,50,106.51,fee schedule,,,77.7,,205.91,percent of total billed charges,,,95,,251.75,percent of total billed charges,,,60,,159,percent of total billed charges,,159,251.75,
XR Hip Min 4 Views Lt w/ Pelvis,3203296,CDM,320,RC,73503,CPT,,,Inpatient,,,265,,LT,,80,,212,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,205.91,percent of total billed charges,,,95,,251.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,251.75,
XR Hip Min 4 Views Rt w/ Pelvis,3203296,CDM,320,RC,73503,CPT,,,Inpatient,,,265,,RT,,80,,212,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,205.91,percent of total billed charges,,,95,,251.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,251.75,
XR Femur Min 2 Views Lt,3203320,CDM,320,RC,73552,CPT,,,Outpatient,,,224,,LT,,80,,179.2,percent of total billed charges,,,,85,190.4,percent of total billed charges,,,77.7,,174.05,percent of total billed charges,,,95,,212.8,percent of total billed charges,,,60,,134.4,percent of total billed charges,,134.4,212.8,
XR Femur Min 2 Views Rt,3203320,CDM,320,RC,73552,CPT,,,Outpatient,,,224,,RT,,80,,179.2,percent of total billed charges,,,,85,190.4,percent of total billed charges,,,77.7,,174.05,percent of total billed charges,,,95,,212.8,percent of total billed charges,,,60,,134.4,percent of total billed charges,,134.4,212.8,
XR Femur Min 2 Views Lt,3203320,CDM,320,RC,73552,CPT,,,Inpatient,,,224,,LT,,80,,179.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,174.05,percent of total billed charges,,,95,,212.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,212.8,
XR Femur Min 2 Views Rt,3203320,CDM,320,RC,73552,CPT,,,Inpatient,,,224,,RT,,80,,179.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,174.05,percent of total billed charges,,,95,,212.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,212.8,
XR Chest 1 View,3203502,CDM,320,RC,71045,CPT,,,Outpatient,,,177,,,,80,,141.6,percent of total billed charges,,,,50,61.79,fee schedule,,,77.7,,137.53,percent of total billed charges,,,95,,168.15,percent of total billed charges,,,60,,106.2,percent of total billed charges,,106.2,168.15,
XR Chest 1 View,3203502,CDM,320,RC,71045,CPT,,,Inpatient,,,177,,,,80,,141.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,137.53,percent of total billed charges,,,95,,168.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,168.15,
XR Chest 2 Views,3203510,CDM,320,RC,71046,CPT,,,Outpatient,,,240,,,,80,,192,percent of total billed charges,,,,50,75.39,fee schedule,,,77.7,,186.48,percent of total billed charges,,,95,,228,percent of total billed charges,,,60,,144,percent of total billed charges,,144,228,
XR Chest 2 Views,3203510,CDM,320,RC,71046,CPT,,,Inpatient,,,240,,,,80,,192,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,186.48,percent of total billed charges,,,95,,228,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,228,
XR Abdomen 2 View,3203551,CDM,320,RC,74019,CPT,,,Outpatient,,,313,,,,80,,250.4,percent of total billed charges,,,,50,50.18,fee schedule,,,77.7,,243.2,percent of total billed charges,,,95,,297.35,percent of total billed charges,,,60,,187.8,percent of total billed charges,,187.8,297.35,
XR Abdomen 2 View,3203551,CDM,320,RC,74019,CPT,,,Inpatient,,,313,,,,80,,250.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,243.2,percent of total billed charges,,,95,,297.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,297.35,
CR Myocardial Spect Multi Studies 78452,3401361,CDM,341,RC,78452,CPT,,,Outpatient,,,2446,,,,80,,1956.8,percent of total billed charges,,,,50,734.04,fee schedule,,,77.7,,1900.54,percent of total billed charges,,,95,,2323.7,percent of total billed charges,,,60,,1467.6,percent of total billed charges,,1467.6,2323.7,
CR Myocardial Spect Multi Studies 78452,3401361,CDM,341,RC,78452,CPT,,,Inpatient,,,2446,,,,80,,1956.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1900.54,percent of total billed charges,,,95,,2323.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2323.7,
CT Head or Brain w/o Contrast,3500030,CDM,350,RC,70450,CPT,,,Outpatient,,,1285,,,,80,,1028,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,998.45,percent of total billed charges,,,95,,1220.75,percent of total billed charges,,,60,,771,percent of total billed charges,,771,1220.75,
CT Head or Brain w/o Contrast,3500030,CDM,350,RC,70450,CPT,,,Inpatient,,,1285,,,,80,,1028,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,998.45,percent of total billed charges,,,95,,1220.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1220.75,
CT Head or Brain w/ + w/o Contrast,3500048,CDM,350,RC,70470,CPT,,,Outpatient,,,1451,,,,80,,1160.8,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,1127.43,percent of total billed charges,,,95,,1378.45,percent of total billed charges,,,60,,870.6,percent of total billed charges,,870.6,1378.45,
CT Head or Brain w/ + w/o Contrast,3500048,CDM,350,RC,70470,CPT,,,Inpatient,,,1451,,,,80,,1160.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1127.43,percent of total billed charges,,,95,,1378.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1378.45,
CT Soft Tissue Neck w/o Contrast,3500063,CDM,350,RC,70490,CPT,,,Outpatient,,,1178,,,,80,,942.4,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,915.31,percent of total billed charges,,,95,,1119.1,percent of total billed charges,,,60,,706.8,percent of total billed charges,,706.8,1119.1,
CT Soft Tissue Neck w/o Contrast,3500063,CDM,350,RC,70490,CPT,,,Inpatient,,,1178,,,,80,,942.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,915.31,percent of total billed charges,,,95,,1119.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1119.1,
CT Neck + Chest + Abdomen + Pelvis w/ +,3500071,CDM,350,RC,70492,CPT,,,Outpatient,,,1208,,,,80,,966.4,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,938.62,percent of total billed charges,,,95,,1147.6,percent of total billed charges,,,60,,724.8,percent of total billed charges,,724.8,1147.6,
CT Neck + Chest + Abdomen + Pelvis w/ +,3500071,CDM,350,RC,70492,CPT,,,Inpatient,,,1208,,,,80,,966.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,938.62,percent of total billed charges,,,95,,1147.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1147.6,
CT Soft Tissue Neck w/ Contrast,3500097,CDM,350,RC,70491,CPT,,,Outpatient,,,1190,,,,80,,952,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,924.63,percent of total billed charges,,,95,,1130.5,percent of total billed charges,,,60,,714,percent of total billed charges,,714,1130.5,
CT Soft Tissue Neck w/ Contrast,3500097,CDM,350,RC,70491,CPT,,,Inpatient,,,1190,,,,80,,952,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,924.63,percent of total billed charges,,,95,,1130.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1130.5,
CT Head or Brain w/ Contrast,3500105,CDM,350,RC,70460,CPT,,,Outpatient,,,1350,,,,80,,1080,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,1048.95,percent of total billed charges,,,95,,1282.5,percent of total billed charges,,,60,,810,percent of total billed charges,,810,1282.5,
CT Head or Brain w/ Contrast,3500105,CDM,350,RC,70460,CPT,,,Inpatient,,,1350,,,,80,,1080,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1048.95,percent of total billed charges,,,95,,1282.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1282.5,
CT Chest w/o Contrast,3500121,CDM,350,RC,71250,CPT,,,Outpatient,,,1250,,,,80,,1000,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,971.25,percent of total billed charges,,,95,,1187.5,percent of total billed charges,,,60,,750,percent of total billed charges,,750,1187.5,
CT Chest w/o Contrast,3500121,CDM,350,RC,71250,CPT,,,Inpatient,,,1250,,,,80,,1000,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,971.25,percent of total billed charges,,,95,,1187.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1187.5,
CT Chest w/ + w/o Contrast,3500139,CDM,350,RC,71270,CPT,,,Outpatient,,,1409,,,,80,,1127.2,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,1094.79,percent of total billed charges,,,95,,1338.55,percent of total billed charges,,,60,,845.4,percent of total billed charges,,845.4,1338.55,
CT Chest w/ + w/o Contrast,3500139,CDM,350,RC,71270,CPT,,,Inpatient,,,1409,,,,80,,1127.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1094.79,percent of total billed charges,,,95,,1338.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1338.55,
CT Abdomen w/o Contrast,3500147,CDM,350,RC,74150,CPT,,,Outpatient,,,1283,,,,80,,1026.4,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,996.89,percent of total billed charges,,,95,,1218.85,percent of total billed charges,,,60,,769.8,percent of total billed charges,,769.8,1218.85,
CT Abdomen w/o Contrast,3500147,CDM,350,RC,74150,CPT,,,Inpatient,,,1283,,,,80,,1026.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,996.89,percent of total billed charges,,,95,,1218.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1218.85,
CT Abdomen w + w/o Contrast + Chest/Pelv,3500154,CDM,350,RC,74170,CPT,,,Outpatient,,,1805,,,,80,,1444,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,1402.49,percent of total billed charges,,,95,,1714.75,percent of total billed charges,,,60,,1083,percent of total billed charges,,1083,1714.75,
CT Abdomen w + w/o Contrast + Chest/Pelv,3500154,CDM,350,RC,74170,CPT,,,Inpatient,,,1805,,,,80,,1444,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1402.49,percent of total billed charges,,,95,,1714.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1714.75,
CT Upper Extremity w/o Contrast Bilat,3500162,CDM,350,RC,73200,CPT,,,Outpatient,,,1172,,,,80,,937.6,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,910.64,percent of total billed charges,,,95,,1113.4,percent of total billed charges,,,60,,703.2,percent of total billed charges,,703.2,1113.4,
CT Upper Extremity w/o Contrast Bilat,3500162,CDM,350,RC,73200,CPT,,,Inpatient,,,1172,,,,80,,937.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,910.64,percent of total billed charges,,,95,,1113.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1113.4,
CT Upper Extremity w/+w/o Contrast Bilat,3500170,CDM,350,RC,73202,CPT,,,Outpatient,,,1351,,,,80,,1080.8,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,1049.73,percent of total billed charges,,,95,,1283.45,percent of total billed charges,,,60,,810.6,percent of total billed charges,,810.6,1283.45,
CT Upper Extremity w/+w/o Contrast Bilat,3500170,CDM,350,RC,73202,CPT,,,Inpatient,,,1351,,,,80,,1080.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1049.73,percent of total billed charges,,,95,,1283.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1283.45,
CT Pelvis w/o Contrast,3500188,CDM,350,RC,72192,CPT,,,Outpatient,,,1425,,,,80,,1140,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,1107.23,percent of total billed charges,,,95,,1353.75,percent of total billed charges,,,60,,855,percent of total billed charges,,855,1353.75,
CT Pelvis w/o Contrast,3500188,CDM,350,RC,72192,CPT,,,Inpatient,,,1425,,,,80,,1140,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1107.23,percent of total billed charges,,,95,,1353.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1353.75,
CT Spine Cervical w/o Contrast,3500204,CDM,350,RC,72125,CPT,,,Outpatient,,,1395,,,,80,,1116,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,1083.92,percent of total billed charges,,,95,,1325.25,percent of total billed charges,,,60,,837,percent of total billed charges,,837,1325.25,
CT Spine Cervical w/o Contrast,3500204,CDM,350,RC,72125,CPT,,,Inpatient,,,1395,,,,80,,1116,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1083.92,percent of total billed charges,,,95,,1325.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1325.25,
CT Orbit Sella etc. w/ + w/o Contrast,3500212,CDM,350,RC,70482,CPT,,,Outpatient,,,1409,,,,80,,1127.2,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,1094.79,percent of total billed charges,,,95,,1338.55,percent of total billed charges,,,60,,845.4,percent of total billed charges,,845.4,1338.55,
CT Orbit Sella etc. w/ + w/o Contrast,3500212,CDM,350,RC,70482,CPT,,,Inpatient,,,1409,,,,80,,1127.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1094.79,percent of total billed charges,,,95,,1338.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1338.55,
CT Maxillofacial w/o Contrast,3500220,CDM,350,RC,70486,CPT,,,Outpatient,,,570.31,,,,80,,456.25,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,443.13,percent of total billed charges,,,95,,541.79,percent of total billed charges,,,60,,342.19,percent of total billed charges,,342.19,541.79,
CT Maxillofacial w/o Contrast,3500220,CDM,350,RC,70486,CPT,,,Inpatient,,,570.31,,,,80,,456.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,443.13,percent of total billed charges,,,95,,541.79,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,541.79,
CT Maxillofacial w/ + w/o Contrast,3500238,CDM,350,RC,70488,CPT,,,Outpatient,,,1409,,,,80,,1127.2,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,1094.79,percent of total billed charges,,,95,,1338.55,percent of total billed charges,,,60,,845.4,percent of total billed charges,,845.4,1338.55,
CT Maxillofacial w/ + w/o Contrast,3500238,CDM,350,RC,70488,CPT,,,Inpatient,,,1409,,,,80,,1127.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1094.79,percent of total billed charges,,,95,,1338.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1338.55,
CT Lower Extremity w/o Contrast Bilat,3500246,CDM,350,RC,73700,CPT,,,Outpatient,,,1155,,,,80,,924,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,897.44,percent of total billed charges,,,95,,1097.25,percent of total billed charges,,,60,,693,percent of total billed charges,,693,1097.25,
CT Lower Extremity w/o Contrast Bilat,3500246,CDM,350,RC,73700,CPT,,,Inpatient,,,1155,,,,80,,924,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,897.44,percent of total billed charges,,,95,,1097.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1097.25,
CT Lower Extremity w/+w/o Contrast Bilat,3500253,CDM,350,RC,73702,CPT,,,Outpatient,,,1351,,,,80,,1080.8,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,1049.73,percent of total billed charges,,,95,,1283.45,percent of total billed charges,,,60,,810.6,percent of total billed charges,,810.6,1283.45,
CT Lower Extremity w/+w/o Contrast Bilat,3500253,CDM,350,RC,73702,CPT,,,Inpatient,,,1351,,,,80,,1080.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1049.73,percent of total billed charges,,,95,,1283.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1283.45,
CT Spine Thoracic w/o Contrast,3500261,CDM,350,RC,72128,CPT,,,Outpatient,,,1505,,,,80,,1204,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,1169.39,percent of total billed charges,,,95,,1429.75,percent of total billed charges,,,60,,903,percent of total billed charges,,903,1429.75,
CT Spine Thoracic w/o Contrast,3500261,CDM,350,RC,72128,CPT,,,Inpatient,,,1505,,,,80,,1204,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1169.39,percent of total billed charges,,,95,,1429.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1429.75,
CT Spine Lumbar w/o Contrast,3500279,CDM,350,RC,72131,CPT,,,Outpatient,,,1505,,,,80,,1204,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,1169.39,percent of total billed charges,,,95,,1429.75,percent of total billed charges,,,60,,903,percent of total billed charges,,903,1429.75,
CT Spine Lumbar w/o Contrast,3500279,CDM,350,RC,72131,CPT,,,Inpatient,,,1505,,,,80,,1204,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1169.39,percent of total billed charges,,,95,,1429.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1429.75,
CT Chest w/ Contrast,3500311,CDM,350,RC,71260,CPT,,,Outpatient,,,1348,,,,80,,1078.4,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,1047.4,percent of total billed charges,,,95,,1280.6,percent of total billed charges,,,60,,808.8,percent of total billed charges,,808.8,1280.6,
CT Chest w/ Contrast,3500311,CDM,350,RC,71260,CPT,,,Inpatient,,,1348,,,,80,,1078.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1047.4,percent of total billed charges,,,95,,1280.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1280.6,
CT Abdomen w/ Contrast,3500329,CDM,350,RC,74160,CPT,,,Outpatient,,,1393,,,,80,,1114.4,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,1082.36,percent of total billed charges,,,95,,1323.35,percent of total billed charges,,,60,,835.8,percent of total billed charges,,835.8,1323.35,
CT Abdomen w/ Contrast,3500329,CDM,350,RC,74160,CPT,,,Inpatient,,,1393,,,,80,,1114.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1082.36,percent of total billed charges,,,95,,1323.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1323.35,
CT Pelvis w/ Contrast,3500352,CDM,350,RC,72193,CPT,,,Outpatient,,,1503,,,,80,,1202.4,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,1167.83,percent of total billed charges,,,95,,1427.85,percent of total billed charges,,,60,,901.8,percent of total billed charges,,901.8,1427.85,
CT Pelvis w/ Contrast,3500352,CDM,350,RC,72193,CPT,,,Inpatient,,,1503,,,,80,,1202.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1167.83,percent of total billed charges,,,95,,1427.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1427.85,
CT Spine Thoracic w/ Contrast,3500378,CDM,350,RC,72129,CPT,,,Outpatient,,,585,,,,80,,468,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,454.55,percent of total billed charges,,,95,,555.75,percent of total billed charges,,,60,,351,percent of total billed charges,,351,555.75,
CT Spine Thoracic w/ Contrast,3500378,CDM,350,RC,72129,CPT,,,Inpatient,,,585,,,,80,,468,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,454.55,percent of total billed charges,,,95,,555.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,555.75,
CT Spine Lumbar w/ Contrast,3500386,CDM,350,RC,72132,CPT,,,Outpatient,,,585,,,,80,,468,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,454.55,percent of total billed charges,,,95,,555.75,percent of total billed charges,,,60,,351,percent of total billed charges,,351,555.75,
CT Spine Lumbar w/ Contrast,3500386,CDM,350,RC,72132,CPT,,,Inpatient,,,585,,,,80,,468,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,454.55,percent of total billed charges,,,95,,555.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,555.75,
CT Angiography Abdomen,3500402,CDM,350,RC,74175,CPT,,,Outpatient,,,2625,,,,80,,2100,percent of total billed charges,,,,50,593.3,fee schedule,,,77.7,,2039.63,percent of total billed charges,,,95,,2493.75,percent of total billed charges,,,60,,1575,percent of total billed charges,,1575,2493.75,
CT Angiography Abdomen,3500402,CDM,350,RC,74175,CPT,,,Inpatient,,,2625,,,,80,,2100,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2039.63,percent of total billed charges,,,95,,2493.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2493.75,
CT IAC w/o Contrast,3500576,CDM,350,RC,70480,CPT,,,Outpatient,,,1158,,,,80,,926.4,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,899.77,percent of total billed charges,,,95,,1100.1,percent of total billed charges,,,60,,694.8,percent of total billed charges,,694.8,1100.1,
CT IAC w/o Contrast,3500576,CDM,350,RC,70480,CPT,,,Inpatient,,,1158,,,,80,,926.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,899.77,percent of total billed charges,,,95,,1100.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1100.1,
CT Angiography Chest for PE,3500592,CDM,350,RC,71275,CPT,,,Outpatient,,,2795,,,,80,,2236,percent of total billed charges,,,,50,571.93,fee schedule,,,77.7,,2171.72,percent of total billed charges,,,95,,2655.25,percent of total billed charges,,,60,,1677,percent of total billed charges,,1677,2655.25,
CT Angiography Chest for PE,3500592,CDM,350,RC,71275,CPT,,,Inpatient,,,2795,,,,80,,2236,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2171.72,percent of total billed charges,,,95,,2655.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2655.25,
CT Angiography Neck w/ + w/o Contrast,3500634,CDM,350,RC,70498,CPT,,,Outpatient,,,2625,,,,80,,2100,percent of total billed charges,,,,50,579.82,fee schedule,,,77.7,,2039.63,percent of total billed charges,,,95,,2493.75,percent of total billed charges,,,60,,1575,percent of total billed charges,,1575,2493.75,
CT Angiography Neck w/ + w/o Contrast,3500634,CDM,350,RC,70498,CPT,,,Inpatient,,,2625,,,,80,,2100,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2039.63,percent of total billed charges,,,95,,2493.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2493.75,
CT Angiography Head w/ + w/o Contrast,3500642,CDM,350,RC,70496,CPT,,,Outpatient,,,2825,,,,80,,2260,percent of total billed charges,,,,50,579.36,fee schedule,,,77.7,,2195.03,percent of total billed charges,,,95,,2683.75,percent of total billed charges,,,60,,1695,percent of total billed charges,,1695,2683.75,
CT Angiography Head w/ + w/o Contrast,3500642,CDM,350,RC,70496,CPT,,,Inpatient,,,2825,,,,80,,2260,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2195.03,percent of total billed charges,,,95,,2683.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2683.75,
CT Angiography Abd Aorta + Iliofemoral,3500659,CDM,350,RC,75635,CPT,,,Outpatient,,,3528,,,,80,,2822.4,percent of total billed charges,,,,50,624.89,fee schedule,,,77.7,,2741.26,percent of total billed charges,,,95,,3351.6,percent of total billed charges,,,60,,2116.8,percent of total billed charges,,2116.8,3351.6,
CT Angiography Abd Aorta + Iliofemoral,3500659,CDM,350,RC,75635,CPT,,,Inpatient,,,3528,,,,80,,2822.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2741.26,percent of total billed charges,,,95,,3351.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3351.6,
CT Angiography Lower Extremity Left,3500667,CDM,350,RC,73706,CPT,,,Outpatient,,,2625,,,,80,,2100,percent of total billed charges,,,,85,2231.25,percent of total billed charges,,,77.7,,2039.63,percent of total billed charges,,,95,,2493.75,percent of total billed charges,,,60,,1575,percent of total billed charges,,1575,2493.75,
CT Angiography Lower Extremity Left,3500667,CDM,350,RC,73706,CPT,,,Inpatient,,,2625,,,,80,,2100,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2039.63,percent of total billed charges,,,95,,2493.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2493.75,
CT Abdomen + Pelvis w/o Contrast,3500717,CDM,350,RC,74176,CPT,,,Outpatient,,,2300,,,,80,,1840,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,1787.1,percent of total billed charges,,,95,,2185,percent of total billed charges,,,60,,1380,percent of total billed charges,,1380,2185,
CT Abdomen + Pelvis w/o Contrast,3500717,CDM,350,RC,74176,CPT,,,Inpatient,,,2300,,,,80,,1840,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1787.1,percent of total billed charges,,,95,,2185,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2185,
CT Abdomen + Pelvis w/ Contrast,3500725,CDM,350,RC,74177,CPT,,,Outpatient,,,2431,,,,80,,1944.8,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,1888.89,percent of total billed charges,,,95,,2309.45,percent of total billed charges,,,60,,1458.6,percent of total billed charges,,1458.6,2309.45,
CT Abdomen + Pelvis w/ Contrast,3500725,CDM,350,RC,74177,CPT,,,Inpatient,,,2431,,,,80,,1944.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1888.89,percent of total billed charges,,,95,,2309.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2309.45,
CT Abdomen + Pelvis w/ + w/o Contrast,3500733,CDM,350,RC,74178,CPT,,,Outpatient,,,2440,,,,80,,1952,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,1895.88,percent of total billed charges,,,95,,2318,percent of total billed charges,,,60,,1464,percent of total billed charges,,1464,2318,
CT Abdomen + Pelvis w/ + w/o Contrast,3500733,CDM,350,RC,74178,CPT,,,Inpatient,,,2440,,,,80,,1952,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1895.88,percent of total billed charges,,,95,,2318,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2318,
CT Angiography of Abdomen + Pelvis,3500741,CDM,350,RC,74174,CPT,,,Outpatient,,,2625,,,,80,,2100,percent of total billed charges,,,,50,852.08,fee schedule,,,77.7,,2039.63,percent of total billed charges,,,95,,2493.75,percent of total billed charges,,,60,,1575,percent of total billed charges,,1575,2493.75,
CT Angiography of Abdomen + Pelvis,3500741,CDM,350,RC,74174,CPT,,,Inpatient,,,2625,,,,80,,2100,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2039.63,percent of total billed charges,,,95,,2493.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2493.75,
CT Low Dose Lung Cancer Screening,3500816,CDM,350,RC,71271,CPT,,,Outpatient,,,700,,,,80,,560,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,543.9,percent of total billed charges,,,95,,665,percent of total billed charges,,,60,,420,percent of total billed charges,,420,665,
CT Low Dose Lung Cancer Screening,3500816,CDM,350,RC,71271,CPT,,,Inpatient,,,700,,,,80,,560,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,543.9,percent of total billed charges,,,95,,665,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,665,
US Head/Neck Soft Tissue,4000055,CDM,402,RC,76536,CPT,,,Outpatient,,,632,,,,80,,505.6,percent of total billed charges,,,,50,240.38,fee schedule,,,77.7,,491.06,percent of total billed charges,,,95,,600.4,percent of total billed charges,,,60,,379.2,percent of total billed charges,,379.2,600.4,
US Thyroid,4000055,CDM,402,RC,76536,CPT,,,Outpatient,,,632,,,,80,,505.6,percent of total billed charges,,,,50,240.38,fee schedule,,,77.7,,491.06,percent of total billed charges,,,95,,600.4,percent of total billed charges,,,60,,379.2,percent of total billed charges,,379.2,600.4,
US Head/Neck Soft Tissue,4000055,CDM,402,RC,76536,CPT,,,Inpatient,,,632,,,,80,,505.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,491.06,percent of total billed charges,,,95,,600.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,600.4,
US Thyroid,4000055,CDM,402,RC,76536,CPT,,,Inpatient,,,632,,,,80,,505.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,491.06,percent of total billed charges,,,95,,600.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,600.4,
US Abdomen Complete,4000071,CDM,402,RC,76700,CPT,,,Outpatient,,,502,,,,80,,401.6,percent of total billed charges,,,,50,75.75,fee schedule,,,77.7,,390.05,percent of total billed charges,,,95,,476.9,percent of total billed charges,,,60,,301.2,percent of total billed charges,,301.2,476.9,
US Abdomen Complete,4000071,CDM,402,RC,76700,CPT,,,Inpatient,,,502,,,,80,,401.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,390.05,percent of total billed charges,,,95,,476.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,476.9,
US Abdomen Limited,4000089,CDM,402,RC,76705,CPT,,,Outpatient,,,439,,,,80,,351.2,percent of total billed charges,,,,50,58.58,fee schedule,,,77.7,,341.1,percent of total billed charges,,,95,,417.05,percent of total billed charges,,,60,,263.4,percent of total billed charges,,263.4,417.05,
US Abdomen Limited,4000089,CDM,402,RC,76705,CPT,,,Inpatient,,,439,,,,80,,351.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,341.1,percent of total billed charges,,,95,,417.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,417.05,
US Renal Complete,4000105,CDM,402,RC,76770,CPT,,,Outpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,50,75.75,fee schedule,,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,60,,250.8,percent of total billed charges,,250.8,397.1,
US Renal Complete,4000105,CDM,402,RC,76770,CPT,,,Inpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,397.1,
US Pregnancy After 1st Trimester,4000113,CDM,402,RC,76805,CPT,,,Outpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,50,66.16,fee schedule,,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,60,,250.8,percent of total billed charges,,250.8,397.1,
US Pregnancy After 1st Trimester,4000113,CDM,402,RC,76805,CPT,,,Inpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,397.1,
US Pregnancy Follow Up,4000121,CDM,402,RC,76816,CPT,,,Outpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,50,70.75,fee schedule,,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,60,,250.8,percent of total billed charges,,250.8,397.1,
US Pregnancy Follow Up,4000121,CDM,402,RC,76816,CPT,,,Inpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,397.1,
US Scrotum (Contents),4000139,CDM,402,RC,76870,CPT,,,Outpatient,,,500,,,,80,,400,percent of total billed charges,,,,50,61.61,fee schedule,,,77.7,,388.5,percent of total billed charges,,,95,,475,percent of total billed charges,,,60,,300,percent of total billed charges,,300,475,
US Scrotum (Contents),4000139,CDM,402,RC,76870,CPT,,,Inpatient,,,500,,,,80,,400,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,388.5,percent of total billed charges,,,95,,475,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,475,
US Pelvis Non OB Complete,4000147,CDM,402,RC,76856,CPT,,,Outpatient,,,495,,,,80,,396,percent of total billed charges,,,,50,61.61,fee schedule,,,77.7,,384.62,percent of total billed charges,,,95,,470.25,percent of total billed charges,,,60,,297,percent of total billed charges,,297,470.25,
US Pelvis Non OB Complete,4000147,CDM,402,RC,76856,CPT,,,Inpatient,,,495,,,,80,,396,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,384.62,percent of total billed charges,,,95,,470.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,470.25,
US Pregnancy Limited,4000162,CDM,402,RC,76815,CPT,,,Outpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,50,70.75,fee schedule,,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,60,,250.8,percent of total billed charges,,250.8,397.1,
US Pregnancy Limited,4000162,CDM,402,RC,76815,CPT,,,Inpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,397.1,
US Aorta Complete,4000188,CDM,402,RC,76775,CPT,,,Outpatient,,,156,,,,80,,124.8,percent of total billed charges,,,,50,58.58,fee schedule,,,77.7,,121.21,percent of total billed charges,,,95,,148.2,percent of total billed charges,,,60,,93.6,percent of total billed charges,,93.6,148.2,
US Aorta Complete,4000188,CDM,402,RC,76775,CPT,,,Inpatient,,,156,,,,80,,124.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,121.21,percent of total billed charges,,,95,,148.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,148.2,
US Transvaginal Non OB,4000238,CDM,402,RC,76830,CPT,,,Outpatient,,,431,,,,80,,344.8,percent of total billed charges,,,,50,61.61,fee schedule,,,77.7,,334.89,percent of total billed charges,,,95,,409.45,percent of total billed charges,,,60,,258.6,percent of total billed charges,,258.6,409.45,
US Transvaginal Non OB,4000238,CDM,402,RC,76830,CPT,,,Inpatient,,,431,,,,80,,344.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,334.89,percent of total billed charges,,,95,,409.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,409.45,
US Pregnancy After 1st Trim Ea Addl Gest,4000261,CDM,402,RC,76810,CPT,,,Outpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,50,36.87,fee schedule,,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,60,,250.8,percent of total billed charges,,250.8,397.1,
US Pregnancy After 1st Trim Ea Addl Gest,4000261,CDM,402,RC,76810,CPT,,,Inpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,397.1,
US Fetal Biophysical Profile w/ Non Str,4000337,CDM,402,RC,76818,CPT,,,Outpatient,,,481,,,,80,,384.8,percent of total billed charges,,,,50,70.75,fee schedule,,,77.7,,373.74,percent of total billed charges,,,95,,456.95,percent of total billed charges,,,60,,288.6,percent of total billed charges,,288.6,456.95,
US Fetal Biophysical Profile w/ Non Str,4000337,CDM,402,RC,76818,CPT,,,Inpatient,,,481,,,,80,,384.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,373.74,percent of total billed charges,,,95,,456.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,456.95,
US Pelvis Non OB Limited,4000477,CDM,402,RC,76857,CPT,,,Outpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,50,51.51,fee schedule,,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,60,,250.8,percent of total billed charges,,250.8,397.1,
US Pelvis Non OB Limited,4000477,CDM,402,RC,76857,CPT,,,Inpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,397.1,
US Chest,4000600,CDM,402,RC,76604,CPT,,,Outpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,50,55.55,fee schedule,,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,60,,250.8,percent of total billed charges,,250.8,397.1,
US Chest,4000600,CDM,402,RC,76604,CPT,,,Inpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,397.1,
US Fetal Doppler Echo,4000618,CDM,402,RC,76827,CPT,,,Outpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,50,45.45,fee schedule,,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,60,,250.8,percent of total billed charges,,250.8,397.1,
US Fetal Doppler Echo,4000618,CDM,402,RC,76827,CPT,,,Inpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,397.1,
US Fetal Biophysical Profile w/o N Str,4000881,CDM,402,RC,76819,CPT,,,Outpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,50,70.75,fee schedule,,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,60,,250.8,percent of total billed charges,,250.8,397.1,
US Fetal Biophysical Profile w/o N Str,4000881,CDM,402,RC,76819,CPT,,,Inpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,397.1,
US Pregnancy 1st Trimester,4000964,CDM,402,RC,76801,CPT,,,Outpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,50,61.16,fee schedule,,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,60,,250.8,percent of total billed charges,,250.8,397.1,
US Pregnancy 1st Trimester,4000964,CDM,402,RC,76801,CPT,,,Outpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,50,61.16,fee schedule,,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,60,,250.8,percent of total billed charges,,250.8,397.1,
US Pregnancy 1st Trimester,4000964,CDM,402,RC,76801,CPT,,,Inpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,397.1,
US Pregnancy 1st Trimester,4000964,CDM,402,RC,76801,CPT,,,Inpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,397.1,
US Pregnancy 1st Trimester Ea Addl Gest,4000972,CDM,402,RC,76802,CPT,,,Outpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,50,38.89,fee schedule,,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,60,,250.8,percent of total billed charges,,250.8,397.1,
US Pregnancy 1st Trimester Ea Addl Gest,4000972,CDM,402,RC,76802,CPT,,,Inpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,397.1,
US Pregnancy Transvaginal,4000980,CDM,402,RC,76817,CPT,,,Outpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,50,70.75,fee schedule,,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,60,,250.8,percent of total billed charges,,250.8,397.1,
US Pregnancy Transvaginal,4000980,CDM,402,RC,76817,CPT,,,Inpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,397.1,
US Breast Bilateral Complete,4001160,CDM,402,RC,76641,CPT,,,Outpatient,,,836,,50,,80,,668.8,percent of total billed charges,,,,50,47.47,fee schedule,,,77.7,,649.57,percent of total billed charges,,,95,,794.2,percent of total billed charges,,,60,,501.6,percent of total billed charges,,501.6,794.2,
US Breast Right Complete,4001160,CDM,402,RC,76641,CPT,,,Outpatient,,,418,,RT,,80,,334.4,percent of total billed charges,,,,50,47.47,fee schedule,,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,60,,250.8,percent of total billed charges,,250.8,397.1,
US Breast Bilateral Complete,4001160,CDM,402,RC,76641,CPT,,,Inpatient,,,836,,50,,80,,668.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,649.57,percent of total billed charges,,,95,,794.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,794.2,
US Breast Right Complete,4001160,CDM,402,RC,76641,CPT,,,Inpatient,,,418,,RT,,80,,334.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,397.1,
US Breast Left Complete,4001178,CDM,402,RC,76641,CPT,,,Outpatient,,,418,,LT,,80,,334.4,percent of total billed charges,,,,50,47.47,fee schedule,,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,60,,250.8,percent of total billed charges,,250.8,397.1,
US Breast Left Complete,4001178,CDM,402,RC,76641,CPT,,,Inpatient,,,418,,LT,,80,,334.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,397.1,
US Breast Axilla,4004248,CDM,402,RC,76882,CPT,,,Outpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,50,58.58,fee schedule,,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,60,,250.8,percent of total billed charges,,250.8,397.1,
US Extremity Non Vascular Limited,4004248,CDM,402,RC,76882,CPT,,,Outpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,50,58.58,fee schedule,,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,60,,250.8,percent of total billed charges,,250.8,397.1,
US Breast Axilla,4004248,CDM,402,RC,76882,CPT,,,Inpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,397.1,
US Extremity Non Vascular Limited,4004248,CDM,402,RC,76882,CPT,,,Inpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,397.1,
US Guided Thoracentesis,4004271,CDM,400,RC,32555,CPT,,,Outpatient,,,1081.63,,,,80,,865.3,percent of total billed charges,,,,50,431.27,fee schedule,,,77.7,,840.43,percent of total billed charges,,,95,,1027.55,percent of total billed charges,,,60,,648.98,percent of total billed charges,,648.98,1027.55,
US Guided Thoracentesis,4004271,CDM,400,RC,32555,CPT,,,Inpatient,,,1081.63,,,,80,,865.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,840.43,percent of total billed charges,,,95,,1027.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1027.55,
US AAA Screening,4004495,CDM,402,RC,76706,CPT,,,Outpatient,,,190,,,,80,,152,percent of total billed charges,,,,50,75.75,fee schedule,,,77.7,,147.63,percent of total billed charges,,,95,,180.5,percent of total billed charges,,,60,,114,percent of total billed charges,,114,180.5,
US AAA Screening,4004495,CDM,402,RC,76706,CPT,,,Inpatient,,,190,,,,80,,152,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,147.63,percent of total billed charges,,,95,,180.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,180.5,
CPAP Initiation and MGMT,4100202,CDM,410,RC,94660,CPT,,,Outpatient,,,438,,,,80,,350.4,percent of total billed charges,,,,50,135.27,fee schedule,,,77.7,,340.33,percent of total billed charges,,,95,,416.1,percent of total billed charges,,,60,,262.8,percent of total billed charges,,262.8,416.1,
CPAP Initiation and MGMT,4100202,CDM,410,RC,94660,CPT,,,Inpatient,,,438,,,,80,,350.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,340.33,percent of total billed charges,,,95,,416.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,416.1,
Intubation Endotracheal Emergency,4101010,CDM,410,RC,31500,CPT,,,Outpatient,,,396,,,,80,,316.8,percent of total billed charges,,,,85,336.6,percent of total billed charges,,,77.7,,307.69,percent of total billed charges,,,95,,376.2,percent of total billed charges,,,60,,237.6,percent of total billed charges,,237.6,376.2,
Intubation Endotracheal Emergency,4101010,CDM,410,RC,31500,CPT,,,Inpatient,,,396,,,,80,,316.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,307.69,percent of total billed charges,,,95,,376.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,376.2,
G0237 Therapeutic Proc Strg Endur Ea 15Mn,4101457,CDM,460,RC,G0237,HCPCS,,,Outpatient,,,126,,,,80,,100.8,percent of total billed charges,,,,50,23.74,fee schedule,,,77.7,,97.9,percent of total billed charges,,,95,,119.7,percent of total billed charges,,,60,,75.6,percent of total billed charges,,23.74,119.7,
G0237 Therapeutic Proc Strg Endur Ea 15Mn,4101457,CDM,460,RC,G0237,HCPCS,,,Inpatient,,,126,,,,80,,100.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,97.9,percent of total billed charges,,,95,,119.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,119.7,
G0238 Other Resp Proc Indv Per 15 Min,4101465,CDM,460,RC,G0238,HCPCS,,,Outpatient,,,109,,,,80,,87.2,percent of total billed charges,,,,50,23.74,fee schedule,,,77.7,,84.69,percent of total billed charges,,,95,,103.55,percent of total billed charges,,,60,,65.4,percent of total billed charges,,23.74,103.55,
G0238 Other Resp Proc Indv Per 15 Min,4101465,CDM,460,RC,G0238,HCPCS,,,Inpatient,,,109,,,,80,,87.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,84.69,percent of total billed charges,,,95,,103.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,103.55,
G0239 OTHER RESP PROC GROUP PER 15 MIN,4101473,CDM,460,RC,G0239,HCPCS,,,Outpatient,,,154,,,,80,,123.2,percent of total billed charges,,,,50,23.74,fee schedule,,,77.7,,119.66,percent of total billed charges,,,95,,146.3,percent of total billed charges,,,60,,92.4,percent of total billed charges,,23.74,146.3,
G0239 OTHER RESP PROC GROUP PER 15 MIN,4101473,CDM,460,RC,G0239,HCPCS,,,Inpatient,,,154,,,,80,,123.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,119.66,percent of total billed charges,,,95,,146.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,146.3,
Ventilation Assist/MGMT IP/OBS INI,4105128,CDM,410,RC,94002,CPT,,,Outpatient,,,650,,,,80,,520,percent of total billed charges,,,,85,552.5,percent of total billed charges,,,77.7,,505.05,percent of total billed charges,,,95,,617.5,percent of total billed charges,,,60,,390,percent of total billed charges,,390,617.5,
Ventilation Assist/MGMT IP/OBS INI,4105128,CDM,410,RC,94002,CPT,,,Inpatient,,,650,,,,80,,520,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,505.05,percent of total billed charges,,,95,,617.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,617.5,
Therapeutic Exercise Charges 97110,4200028,CDM,421,RC,97110,CPT,,,Outpatient,,,99,,GP,,80,,79.2,percent of total billed charges,,,,50,24.75,fee schedule,,,77.7,,76.92,percent of total billed charges,,,95,,94.05,percent of total billed charges,,,60,,59.4,percent of total billed charges,,59.4,94.05,
Therapeutic Exercise Charges 97110,4200028,CDM,421,RC,97110,CPT,,,Inpatient,,,99,,GP,,80,,79.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,76.92,percent of total billed charges,,,95,,94.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,94.05,
PT Ultrasound Charges 97035,4200150,CDM,421,RC,97035,CPT,,,Outpatient,,,67,,GP,,80,,53.6,percent of total billed charges,,,,50,14.65,fee schedule,,,77.7,,52.06,percent of total billed charges,,,95,,63.65,percent of total billed charges,,,60,,40.2,percent of total billed charges,,40.2,63.65,
PT Ultrasound Charges 97035,4200150,CDM,421,RC,97035,CPT,,,Inpatient,,,67,,GP,,80,,53.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,52.06,percent of total billed charges,,,95,,63.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,63.65,
Mechanical Traction Provided  Units 97012,4200176,CDM,421,RC,97012,CPT,,,Outpatient,,,54,,GP,,80,,43.2,percent of total billed charges,,,,50,18.18,fee schedule,,,77.7,,41.96,percent of total billed charges,,,95,,51.3,percent of total billed charges,,,60,,32.4,percent of total billed charges,,32.4,51.3,
Mechanical Traction Provided  Units 97012,4200176,CDM,421,RC,97012,CPT,,,Inpatient,,,54,,GP,,80,,43.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,41.96,percent of total billed charges,,,95,,51.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,51.3,
PT Massage Charge Units 97124,4200283,CDM,421,RC,97124,CPT,,,Outpatient,,,94,,GP,,80,,75.2,percent of total billed charges,,,,50,21.21,fee schedule,,,77.7,,73.04,percent of total billed charges,,,95,,89.3,percent of total billed charges,,,60,,56.4,percent of total billed charges,,56.4,89.3,
PT Massage Charge Units 97124,4200283,CDM,421,RC,97124,CPT,,,Inpatient,,,94,,GP,,80,,75.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,73.04,percent of total billed charges,,,95,,89.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,89.3,
PT Iontophoresis Charges 97033,4200432,CDM,421,RC,97033,CPT,,,Outpatient,,,116,,GP,,80,,92.8,percent of total billed charges,,,,50,19.19,fee schedule,,,77.7,,90.13,percent of total billed charges,,,95,,110.2,percent of total billed charges,,,60,,69.6,percent of total billed charges,,69.6,110.2,
PT Iontophoresis Charges 97033,4200432,CDM,421,RC,97033,CPT,,,Inpatient,,,116,,GP,,80,,92.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,90.13,percent of total billed charges,,,95,,110.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,110.2,
Gait Training Units 97116,4200606,CDM,421,RC,97116,CPT,,,Outpatient,,,99,,GP,,80,,79.2,percent of total billed charges,,,,50,23.23,fee schedule,,,77.7,,76.92,percent of total billed charges,,,95,,94.05,percent of total billed charges,,,60,,59.4,percent of total billed charges,,59.4,94.05,
Gait Training Units 97116,4200606,CDM,421,RC,97116,CPT,,,Inpatient,,,99,,GP,,80,,79.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,76.92,percent of total billed charges,,,95,,94.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,94.05,
Manual Therapy Charge Units 97140,4200895,CDM,421,RC,97140,CPT,,,Outpatient,,,109,,GP,,80,,87.2,percent of total billed charges,,,,50,25.25,fee schedule,,,77.7,,84.69,percent of total billed charges,,,95,,103.55,percent of total billed charges,,,60,,65.4,percent of total billed charges,,65.4,103.55,
Manual Therapy Charge Units 97140,4200895,CDM,421,RC,97140,CPT,,,Inpatient,,,109,,GP,,80,,87.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,84.69,percent of total billed charges,,,95,,103.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,103.55,
E-STIM Manual/15min Units 97032,4200937,CDM,421,RC,97032,CPT,,,Outpatient,,,62,,GP,,80,,49.6,percent of total billed charges,,,,50,17.17,fee schedule,,,77.7,,48.17,percent of total billed charges,,,95,,58.9,percent of total billed charges,,,60,,37.2,percent of total billed charges,,37.2,58.9,
Ultrasound/E-Stim Combo Units 97032,4200937,CDM,421,RC,97032,CPT,,,Outpatient,,,62,,GP,,80,,49.6,percent of total billed charges,,,,50,17.17,fee schedule,,,77.7,,48.17,percent of total billed charges,,,95,,58.9,percent of total billed charges,,,60,,37.2,percent of total billed charges,,37.2,58.9,
E-STIM Manual/15min Units 97032,4200937,CDM,421,RC,97032,CPT,,,Inpatient,,,62,,GP,,80,,49.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,48.17,percent of total billed charges,,,95,,58.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,58.9,
Ultrasound/E-Stim Combo Units 97032,4200937,CDM,421,RC,97032,CPT,,,Inpatient,,,62,,GP,,80,,49.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,48.17,percent of total billed charges,,,95,,58.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,58.9,
PT Aquatic Units 97113,4201018,CDM,421,RC,97113,CPT,,,Outpatient,,,116,,GP,,80,,92.8,percent of total billed charges,,,,50,26.77,fee schedule,,,77.7,,90.13,percent of total billed charges,,,95,,110.2,percent of total billed charges,,,60,,69.6,percent of total billed charges,,69.6,110.2,
PT Aquatic Units 97113,4201018,CDM,421,RC,97113,CPT,,,Inpatient,,,116,,GP,,80,,92.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,90.13,percent of total billed charges,,,95,,110.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,110.2,
Neuromuscular Reeducation Units 97112,4201026,CDM,421,RC,97112,CPT,,,Outpatient,,,94,,GP,,80,,75.2,percent of total billed charges,,,,50,25.25,fee schedule,,,77.7,,73.04,percent of total billed charges,,,95,,89.3,percent of total billed charges,,,60,,56.4,percent of total billed charges,,56.4,89.3,
Neuromuscular Reeducation Units 97112,4201026,CDM,421,RC,97112,CPT,,,Inpatient,,,94,,GP,,80,,75.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,73.04,percent of total billed charges,,,95,,89.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,89.3,
CONT. Passive Motion/Specify Units,4201513,CDM,421,RC,97139,CPT,,,Outpatient,,,64,,GP,,80,,51.2,percent of total billed charges,,,,85,54.4,percent of total billed charges,,,77.7,,49.73,percent of total billed charges,,,95,,60.8,percent of total billed charges,,,60,,38.4,percent of total billed charges,,38.4,60.8,
CONT. Passive Motion/Specify Units,4201513,CDM,421,RC,97139,CPT,,,Inpatient,,,64,,GP,,80,,51.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,49.73,percent of total billed charges,,,95,,60.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,60.8,
Wheelchair MGMT/15min Units 97542,4201737,CDM,421,RC,97542,CPT,,,Outpatient,,,89,,GP,,80,,71.2,percent of total billed charges,,,,85,75.65,percent of total billed charges,,,77.7,,69.15,percent of total billed charges,,,95,,84.55,percent of total billed charges,,,60,,53.4,percent of total billed charges,,53.4,84.55,
Wheelchair MGMT/15min Units 97542,4201737,CDM,421,RC,97542,CPT,,,Inpatient,,,89,,GP,,80,,71.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,69.15,percent of total billed charges,,,95,,84.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,84.55,
Eval OR W/Measurement Units 97799,4202073,CDM,421,RC,97799,CPT,,,Outpatient,,,106,,GP,,80,,84.8,percent of total billed charges,,,,50,5.05,fee schedule,,,77.7,,82.36,percent of total billed charges,,,95,,100.7,percent of total billed charges,,,60,,63.6,percent of total billed charges,,63.6,100.7,
Eval OR W/Measurement Units 97799,4202073,CDM,421,RC,97799,CPT,,,Inpatient,,,106,,GP,,80,,84.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,82.36,percent of total billed charges,,,95,,100.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,100.7,
PT Group Therapy Charge,4202149,CDM,421,RC,97150,CPT,,,Outpatient,,,91,,GP,,80,,72.8,percent of total billed charges,,,,50,13.26,fee schedule,,,77.7,,70.71,percent of total billed charges,,,95,,86.45,percent of total billed charges,,,60,,54.6,percent of total billed charges,,54.6,86.45,
PT Group Therapy Charge,4202149,CDM,421,RC,97150,CPT,,,Inpatient,,,91,,GP,,80,,72.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,70.71,percent of total billed charges,,,95,,86.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,86.45,
"PT Self Care, Home Management Charges 97535",4202172,CDM,421,RC,97535,CPT,,,Outpatient,,,99,,GP,,80,,79.2,percent of total billed charges,,,,50,17.09,fee schedule,,,77.7,,76.92,percent of total billed charges,,,95,,94.05,percent of total billed charges,,,60,,59.4,percent of total billed charges,,59.4,94.05,
"PT Self Care, Home Management Charges 97535",4202172,CDM,421,RC,97535,CPT,,,Inpatient,,,99,,GP,,80,,79.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,76.92,percent of total billed charges,,,95,,94.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,94.05,
Therapeutic Activities Charge 97530,4202180,CDM,421,RC,97530,CPT,,,Outpatient,,,95,,GP,,80,,76,percent of total billed charges,,,,50,24.75,fee schedule,,,77.7,,73.82,percent of total billed charges,,,95,,90.25,percent of total billed charges,,,60,,57,percent of total billed charges,,57,90.25,
Therapeutic Activities Charge 97530,4202180,CDM,421,RC,97530,CPT,,,Inpatient,,,95,,GP,,80,,76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,73.82,percent of total billed charges,,,95,,90.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,90.25,
PT Parafin Bath Charge 97018,4202446,CDM,421,RC,97018,CPT,,,Outpatient,,,81,,GP,,80,,64.8,percent of total billed charges,,,,50,11.62,fee schedule,,,77.7,,62.94,percent of total billed charges,,,95,,76.95,percent of total billed charges,,,60,,48.6,percent of total billed charges,,48.6,76.95,
PT Parafin Bath Charge 97018,4202446,CDM,421,RC,97018,CPT,,,Inpatient,,,81,,GP,,80,,64.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,62.94,percent of total billed charges,,,95,,76.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,76.95,
Wound Care Non-Selective Debride Charge,4202800,CDM,421,RC,97602,CPT,,,Outpatient,,,252,,GP,,80,,201.6,percent of total billed charges,,,,50,100.1,fee schedule,,,77.7,,195.8,percent of total billed charges,,,95,,239.4,percent of total billed charges,,,60,,151.2,percent of total billed charges,,151.2,239.4,
Wound Care Non-Selective Debride Charge,4202800,CDM,421,RC,97602,CPT,,,Inpatient,,,252,,GP,,80,,201.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,195.8,percent of total billed charges,,,95,,239.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,239.4,
PT Electrical Stimulation Unattended Charge G0283 97014,4202958,CDM,421,RC,97014,CPT,,,Outpatient,,,58,,GP,,80,,46.4,percent of total billed charges,,,,50,15.66,fee schedule,,,77.7,,45.07,percent of total billed charges,,,95,,55.1,percent of total billed charges,,,60,,34.8,percent of total billed charges,,34.8,55.1,
PT Electrical Stimulation Unattended Charge G0283 97014,4202958,CDM,421,RC,97014,CPT,,,Inpatient,,,58,,GP,,80,,46.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,45.07,percent of total billed charges,,,95,,55.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,55.1,
Wound Care Selective Debridement Charge,4203063,CDM,421,RC,97597,CPT,,,Outpatient,,,276,,GP,,80,,220.8,percent of total billed charges,,,,50,139.38,fee schedule,,,77.7,,214.45,percent of total billed charges,,,95,,262.2,percent of total billed charges,,,60,,165.6,percent of total billed charges,,165.6,262.2,
Wound Care Selective Debridement Charge,4203063,CDM,421,RC,97597,CPT,,,Inpatient,,,276,,GP,,80,,220.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,214.45,percent of total billed charges,,,95,,262.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,262.2,
PT Canalith Repositioning Charge 95992,4203261,CDM,421,RC,95992,CPT,,,Outpatient,,,62,,GP,,80,,49.6,percent of total billed charges,,,,50,20.07,fee schedule,,,77.7,,48.17,percent of total billed charges,,,95,,58.9,percent of total billed charges,,,60,,37.2,percent of total billed charges,,37.2,58.9,
PT Canalith Repositioning Charge 95992,4203261,CDM,421,RC,95992,CPT,,,Inpatient,,,62,,GP,,80,,49.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,48.17,percent of total billed charges,,,95,,58.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,58.9,
PT Low Complex Units 97161,4203394,CDM,424,RC,97161,CPT,,,Outpatient,,,235,,GP,,80,,188,percent of total billed charges,,,,50,60.3,fee schedule,,,77.7,,182.6,percent of total billed charges,,,95,,223.25,percent of total billed charges,,,60,,141,percent of total billed charges,,141,223.25,
PT Low Complex Units 97161,4203394,CDM,424,RC,97161,CPT,,,Inpatient,,,235,,GP,,80,,188,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,182.6,percent of total billed charges,,,95,,223.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,223.25,
PT Moderate Complex Units 97162,4203402,CDM,424,RC,97162,CPT,,,Outpatient,,,268,,GP,,80,,214.4,percent of total billed charges,,,,50,60.3,fee schedule,,,77.7,,208.24,percent of total billed charges,,,95,,254.6,percent of total billed charges,,,60,,160.8,percent of total billed charges,,160.8,254.6,
PT Moderate Complex Units 97162,4203402,CDM,424,RC,97162,CPT,,,Inpatient,,,268,,GP,,80,,214.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,208.24,percent of total billed charges,,,95,,254.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,254.6,
PT High Complex Units 97163,4203410,CDM,424,RC,97163,CPT,,,Outpatient,,,309,,GP,,80,,247.2,percent of total billed charges,,,,50,60.3,fee schedule,,,77.7,,240.09,percent of total billed charges,,,95,,293.55,percent of total billed charges,,,60,,185.4,percent of total billed charges,,185.4,293.55,
PT High Complex Units 97163,4203410,CDM,424,RC,97163,CPT,,,Inpatient,,,309,,GP,,80,,247.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,240.09,percent of total billed charges,,,95,,293.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,293.55,
PT ReEval Units 97164,4203428,CDM,424,RC,97164,CPT,,,Outpatient,,,165,,GP,,80,,132,percent of total billed charges,,,,50,40.67,fee schedule,,,77.7,,128.21,percent of total billed charges,,,95,,156.75,percent of total billed charges,,,60,,99,percent of total billed charges,,99,156.75,
PT ReEval Units 97164,4203428,CDM,424,RC,97164,CPT,,,Inpatient,,,165,,GP,,80,,132,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,128.21,percent of total billed charges,,,95,,156.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,156.75,
Orthotic Training Units 97760,4203444,CDM,421,RC,97760,CPT,,,Outpatient,,,91,,GP,,80,,72.8,percent of total billed charges,,,,50,19.82,fee schedule,,,77.7,,70.71,percent of total billed charges,,,95,,86.45,percent of total billed charges,,,60,,54.6,percent of total billed charges,,54.6,86.45,
Orthotic Training Units 97760,4203444,CDM,421,RC,97760,CPT,,,Inpatient,,,91,,GP,,80,,72.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,70.71,percent of total billed charges,,,95,,86.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,86.45,
PT Prosthetic Training Charges 97761,4203451,CDM,421,RC,97761,CPT,,,Outpatient,,,116,,GP,,80,,92.8,percent of total billed charges,,,,50,25.25,fee schedule,,,77.7,,90.13,percent of total billed charges,,,95,,110.2,percent of total billed charges,,,60,,69.6,percent of total billed charges,,69.6,110.2,
PT Prosthetic Training Charges 97761,4203451,CDM,421,RC,97761,CPT,,,Inpatient,,,116,,GP,,80,,92.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,90.13,percent of total billed charges,,,95,,110.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,110.2,
Cognitive Perform Test Stnd Per Hr Units 96125,4301511,CDM,440,RC,96125,CPT,,,Outpatient,,,284,,GN,,80,,227.2,percent of total billed charges,,,,85,241.4,percent of total billed charges,,,77.7,,220.67,percent of total billed charges,,,95,,269.8,percent of total billed charges,,,60,,170.4,percent of total billed charges,,170.4,269.8,
Cognitive Perform Test Stnd Per Hr Units 96125,4301511,CDM,440,RC,96125,CPT,,,Inpatient,,,284,,GN,,80,,227.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,220.67,percent of total billed charges,,,95,,269.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,269.8,
"Treatment of Speech,Lang,Voice Units 92507",4400065,CDM,441,RC,92507,CPT,,,Outpatient,,,98,,GN,,80,,78.4,percent of total billed charges,,,,50,38.89,fee schedule,,,77.7,,76.15,percent of total billed charges,,,95,,93.1,percent of total billed charges,,,60,,58.8,percent of total billed charges,,58.8,93.1,
"Treatment of Speech,Lang,Voice Units 92507",4400065,CDM,441,RC,92507,CPT,,,Inpatient,,,98,,GN,,80,,78.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,76.15,percent of total billed charges,,,95,,93.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,93.1,
Swallow Evaluation Charge,4400073,CDM,424,RC,92610,CPT,,,Outpatient,,,249,,GN,,80,,199.2,percent of total billed charges,,,,50,64.36,fee schedule,,,77.7,,193.47,percent of total billed charges,,,95,,236.55,percent of total billed charges,,,60,,149.4,percent of total billed charges,,149.4,236.55,
Swallow Evaluation Charge,4400073,CDM,424,RC,92610,CPT,,,Inpatient,,,249,,GN,,80,,199.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,193.47,percent of total billed charges,,,95,,236.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,236.55,
Treatment of Swallowing Dysfunction Unit 92526,4400131,CDM,440,RC,92526,CPT,,,Outpatient,,,185,,GN,,80,,148,percent of total billed charges,,,,50,32.72,fee schedule,,,77.7,,143.75,percent of total billed charges,,,95,,175.75,percent of total billed charges,,,60,,111,percent of total billed charges,,111,175.75,
Treatment of Swallowing Dysfunction Unit 92526,4400131,CDM,440,RC,92526,CPT,,,Inpatient,,,185,,GN,,80,,148,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,143.75,percent of total billed charges,,,95,,175.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,175.75,
Swallow Funct Fluoroscopic Eval Units 92611,4400412,CDM,444,RC,92611,CPT,,,Outpatient,,,265,,GN,,80,,212,percent of total billed charges,,,,50,89.11,fee schedule,,,77.7,,205.91,percent of total billed charges,,,95,,251.75,percent of total billed charges,,,60,,159,percent of total billed charges,,159,251.75,
Swallow Funct Fluoroscopic Eval Units 92611,4400412,CDM,444,RC,92611,CPT,,,Inpatient,,,265,,GN,,80,,212,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,205.91,percent of total billed charges,,,95,,251.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,251.75,
Speech Eval of Speech Fluency Units 92521,4400610,CDM,444,RC,92521,CPT,,,Outpatient,,,213,,GN,,80,,170.4,percent of total billed charges,,,,50,58.08,fee schedule,,,77.7,,165.5,percent of total billed charges,,,95,,202.35,percent of total billed charges,,,60,,127.8,percent of total billed charges,,127.8,202.35,
Speech Eval of Speech Fluency Units 92521,4400610,CDM,444,RC,92521,CPT,,,Inpatient,,,213,,GN,,80,,170.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,165.5,percent of total billed charges,,,95,,202.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,202.35,
Speech Eval Speech Production Units 92522,4400628,CDM,444,RC,92522,CPT,,,Outpatient,,,146,,GN,,80,,116.8,percent of total billed charges,,,,50,58.08,fee schedule,,,77.7,,113.44,percent of total billed charges,,,95,,138.7,percent of total billed charges,,,60,,87.6,percent of total billed charges,,87.6,138.7,
Speech Eval Speech Production Units 92522,4400628,CDM,444,RC,92522,CPT,,,Inpatient,,,146,,GN,,80,,116.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,113.44,percent of total billed charges,,,95,,138.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,138.7,
Speech Sound Lang Comprehen Eval Units 92523,4400636,CDM,444,RC,92523,CPT,,,Outpatient,,,146,,GN,,80,,116.8,percent of total billed charges,,,,50,58.08,fee schedule,,,77.7,,113.44,percent of total billed charges,,,95,,138.7,percent of total billed charges,,,60,,87.6,percent of total billed charges,,87.6,138.7,
Speech Sound Lang Comprehen Eval Units 92523,4400636,CDM,444,RC,92523,CPT,,,Inpatient,,,146,,GN,,80,,116.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,113.44,percent of total billed charges,,,95,,138.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,138.7,
Speech Behavral Qualit Analys Voice Units 92524,4400644,CDM,444,RC,92524,CPT,,,Outpatient,,,120,,GN,,80,,96,percent of total billed charges,,,,50,58.08,fee schedule,,,77.7,,93.24,percent of total billed charges,,,95,,114,percent of total billed charges,,,60,,72,percent of total billed charges,,72,114,
Speech Behavral Qualit Analys Voice Units 92524,4400644,CDM,444,RC,92524,CPT,,,Inpatient,,,120,,GN,,80,,96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,93.24,percent of total billed charges,,,95,,114,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,114,
99281 - Level 1,4500013,CDM,450,RC,99281,CPT,,,Outpatient,,,225,,,,80,,180,percent of total billed charges,,,,50,85.16,fee schedule,,,77.7,,174.83,percent of total billed charges,,,95,,213.75,percent of total billed charges,,,60,,135,percent of total billed charges,,135,213.75,
99281 - Level 1,4500013,CDM,450,RC,99281,CPT,,,Inpatient,,,225,,,,80,,180,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,174.83,percent of total billed charges,,,95,,213.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,213.75,
99283 - Level 3,4500021,CDM,450,RC,99283,CPT,,,Outpatient,,,600,,,,80,,480,percent of total billed charges,,,,50,203.9,fee schedule,,,77.7,,466.2,percent of total billed charges,,,95,,570,percent of total billed charges,,,60,,360,percent of total billed charges,,360,570,
99283 - Level 3,4500021,CDM,450,RC,99283,CPT,,,Inpatient,,,600,,,,80,,480,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,466.2,percent of total billed charges,,,95,,570,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,570,
99284 - Level 4,4500039,CDM,450,RC,99284,CPT,,,Outpatient,,,932,,,,80,,745.6,percent of total billed charges,,,,50,347.62,fee schedule,,,77.7,,724.16,percent of total billed charges,,,95,,885.4,percent of total billed charges,,,60,,559.2,percent of total billed charges,,559.2,885.4,
99284 - Level 4,4500039,CDM,450,RC,99284,CPT,,,Inpatient,,,932,,,,80,,745.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,724.16,percent of total billed charges,,,95,,885.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,885.4,
99291 - Critical Care,4500047,CDM,450,RC,99291,CPT,,,Outpatient,,,2017,,,,80,,1613.6,percent of total billed charges,,,,50,510.9,fee schedule,,,77.7,,1567.21,percent of total billed charges,,,95,,1916.15,percent of total billed charges,,,60,,1210.2,percent of total billed charges,,1210.2,1916.15,
99291 - Critical Care,4500047,CDM,450,RC,99291,CPT,,,Inpatient,,,2017,,,,80,,1613.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1567.21,percent of total billed charges,,,95,,1916.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1916.15,
"99292 - Critical Care, each 30 min",4500054,CDM,450,RC,99292,CPT,,,Outpatient,,,411,,,,80,,328.8,percent of total billed charges,,,,50,151.65,fee schedule,,,77.7,,319.35,percent of total billed charges,,,95,,390.45,percent of total billed charges,,,60,,246.6,percent of total billed charges,,246.6,390.45,
"99292 - Critical Care, each 30 min",4500054,CDM,450,RC,99292,CPT,,,Inpatient,,,411,,,,80,,328.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,319.35,percent of total billed charges,,,95,,390.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,390.45,
99285 - Level 5,4500781,CDM,450,RC,99285,CPT,,,Outpatient,,,1420,,,,80,,1136,percent of total billed charges,,,,50,540.27,fee schedule,,,77.7,,1103.34,percent of total billed charges,,,95,,1349,percent of total billed charges,,,60,,852,percent of total billed charges,,852,1349,
99285 - Level 5,4500781,CDM,450,RC,99285,CPT,,,Inpatient,,,1420,,,,80,,1136,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1103.34,percent of total billed charges,,,95,,1349,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1349,
99282 - Level 2,4500799,CDM,450,RC,99282,CPT,,,Outpatient,,,410,,,,80,,328,percent of total billed charges,,,,50,132.66,fee schedule,,,77.7,,318.57,percent of total billed charges,,,95,,389.5,percent of total billed charges,,,60,,246,percent of total billed charges,,246,389.5,
99282 - Level 2,4500799,CDM,450,RC,99282,CPT,,,Inpatient,,,410,,,,80,,328,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,318.57,percent of total billed charges,,,95,,389.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,389.5,
ER 10060 I&D ABSCESS SIMPLE/SINGLE,4501813,CDM,450,RC,10060,CPT,,,Outpatient,,,1115,,,,80,,892,percent of total billed charges,,,,50,108.86,fee schedule,,,77.7,,866.36,percent of total billed charges,,,95,,1059.25,percent of total billed charges,,,60,,669,percent of total billed charges,,669,1059.25,
ER 10060 I&D ABSCESS SIMPLE/SINGLE,4501813,CDM,450,RC,10060,CPT,,,Inpatient,,,1115,,,,80,,892,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,866.36,percent of total billed charges,,,95,,1059.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1059.25,
ER 92950 CARDIOPULMONARY RESUSCITATION ER Charge,4502340,CDM,450,RC,92950,CPT,,,Outpatient,,,542,,,,80,,433.6,percent of total billed charges,,,,50,154.75,fee schedule,,,77.7,,421.13,percent of total billed charges,,,95,,514.9,percent of total billed charges,,,60,,325.2,percent of total billed charges,,325.2,514.9,
ER 92950 CARDIOPULMONARY RESUSCITATION ER Charge,4502340,CDM,450,RC,92950,CPT,,,Inpatient,,,542,,,,80,,433.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,421.13,percent of total billed charges,,,95,,514.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,514.9,
"96360- Hydration, first hour",4503041,CDM,450,RC,96360,CPT,,,Outpatient,,,339,,,,80,,271.2,percent of total billed charges,,,,50,114.91,fee schedule,,,77.7,,263.4,percent of total billed charges,,,95,,322.05,percent of total billed charges,,,60,,203.4,percent of total billed charges,,203.4,322.05,
"96360- Hydration, first hour",4503041,CDM,450,RC,96360,CPT,,,Inpatient,,,339,,,,80,,271.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,263.4,percent of total billed charges,,,95,,322.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,322.05,
96365- IV Therapy Initial 16-90 MIN,4503058,CDM,450,RC,96365,CPT,,,Outpatient,,,339,,,,80,,271.2,percent of total billed charges,,,,50,114.91,fee schedule,,,77.7,,263.4,percent of total billed charges,,,95,,322.05,percent of total billed charges,,,60,,203.4,percent of total billed charges,,203.4,322.05,
96365- IV Therapy Initial 16-90 MIN,4503058,CDM,450,RC,96365,CPT,,,Inpatient,,,339,,,,80,,271.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,263.4,percent of total billed charges,,,95,,322.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,322.05,
"96361- Hydration, each additional hour",4503066,CDM,450,RC,96361,CPT,,,Outpatient,,,171,,,,80,,136.8,percent of total billed charges,,,,50,66.66,fee schedule,,,77.7,,132.87,percent of total billed charges,,,95,,162.45,percent of total billed charges,,,60,,102.6,percent of total billed charges,,102.6,162.45,
"96361- Hydration, each additional hour",4503066,CDM,450,RC,96361,CPT,,,Inpatient,,,171,,,,80,,136.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,132.87,percent of total billed charges,,,95,,162.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,162.45,
96366 IV THER. ADD'L HRS > 91 MINS Charge,4503074,CDM,450,RC,96366,CPT,,,Outpatient,,,168,,,,80,,134.4,percent of total billed charges,,,,50,66.66,fee schedule,,,77.7,,130.54,percent of total billed charges,,,95,,159.6,percent of total billed charges,,,60,,100.8,percent of total billed charges,,100.8,159.6,
96366 IV THER. ADD'L HRS > 91 MINS Charge,4503074,CDM,450,RC,96366,CPT,,,Inpatient,,,168,,,,80,,134.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,130.54,percent of total billed charges,,,95,,159.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,159.6,
"96367- IV tx, sequential infusion",4503082,CDM,450,RC,96367,CPT,,,Outpatient,,,168,,,,80,,134.4,percent of total billed charges,,,,50,66.66,fee schedule,,,77.7,,130.54,percent of total billed charges,,,95,,159.6,percent of total billed charges,,,60,,100.8,percent of total billed charges,,100.8,159.6,
"96367- IV tx, sequential infusion",4503082,CDM,450,RC,96367,CPT,,,Inpatient,,,168,,,,80,,134.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,130.54,percent of total billed charges,,,95,,159.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,159.6,
96372- Subq/IM Injection,4503116,CDM,450,RC,96372,CPT,,,Outpatient,,,135,,,,80,,108,percent of total billed charges,,,,50,34.83,fee schedule,,,77.7,,104.9,percent of total billed charges,,,95,,128.25,percent of total billed charges,,,60,,81,percent of total billed charges,,81,128.25,
96372- Subq/IM Injection,4503116,CDM,450,RC,96372,CPT,,,Inpatient,,,135,,,,80,,108,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,104.9,percent of total billed charges,,,95,,128.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,128.25,
"96374- IV Injection, single/initial",4503249,CDM,450,RC,96374,CPT,,,Outpatient,,,339,,,,80,,271.2,percent of total billed charges,,,,50,114.91,fee schedule,,,77.7,,263.4,percent of total billed charges,,,95,,322.05,percent of total billed charges,,,60,,203.4,percent of total billed charges,,203.4,322.05,
"96374- IV Injection, single/initial",4503249,CDM,450,RC,96374,CPT,,,Inpatient,,,339,,,,80,,271.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,263.4,percent of total billed charges,,,95,,322.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,322.05,
"96375- IV Injection, add new drug",4503272,CDM,450,RC,96375,CPT,,,Outpatient,,,87,,,,80,,69.6,percent of total billed charges,,,,50,21.72,fee schedule,,,77.7,,67.6,percent of total billed charges,,,95,,82.65,percent of total billed charges,,,60,,52.2,percent of total billed charges,,52.2,82.65,
"96375- IV Injection, add new drug",4503272,CDM,450,RC,96375,CPT,,,Inpatient,,,87,,,,80,,69.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,67.6,percent of total billed charges,,,95,,82.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,82.65,
ER 51701 INSERT STRAIGHT CATHETER ER,4503348,CDM,450,RC,51701,CPT,,,Outpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,50,72.45,fee schedule,,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,60,,157.06,percent of total billed charges,,157.06,248.68,
ER 51701 INSERT STRAIGHT CATHETER ER,4503348,CDM,450,RC,51701,CPT,,,Inpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,248.68,
"96376- IV Injection, add same drug",4503520,CDM,450,RC,96376,CPT,,,Outpatient,,,71,,,,80,,56.8,percent of total billed charges,,,,50,21.72,fee schedule,,,77.7,,55.17,percent of total billed charges,,,95,,67.45,percent of total billed charges,,,60,,42.6,percent of total billed charges,,42.6,67.45,
"96376- IV Injection, add same drug",4503520,CDM,450,RC,96376,CPT,,,Inpatient,,,71,,,,80,,56.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,55.17,percent of total billed charges,,,95,,67.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,67.45,
ER 51702 INSERT FOLEY CATHETER SIMPLE,4503876,CDM,450,RC,51702,CPT,,,Outpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,50,72.45,fee schedule,,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,60,,157.06,percent of total billed charges,,157.06,248.68,
ER 51702 INSERT FOLEY CATHETER SIMPLE,4503876,CDM,450,RC,51702,CPT,,,Inpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,248.68,
ER 29131 SPLINT APPL FINGER DYNAMIC,4504205,CDM,450,RC,29131,CPT,,,Outpatient,,,323,,,,80,,258.4,percent of total billed charges,,,,50,115.14,fee schedule,,,77.7,,250.97,percent of total billed charges,,,95,,306.85,percent of total billed charges,,,60,,193.8,percent of total billed charges,,193.8,306.85,
ER 29131 SPLINT APPL FINGER DYNAMIC,4504205,CDM,450,RC,29131,CPT,,,Inpatient,,,323,,,,80,,258.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,250.97,percent of total billed charges,,,95,,306.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,306.85,
ER 20605 ARTHROCENT/ASP/INJ INT JNT WO US,4504239,CDM,450,RC,20605,CPT,,,Outpatient,,,456,,,,80,,364.8,percent of total billed charges,,,,50,165.27,fee schedule,,,77.7,,354.31,percent of total billed charges,,,95,,433.2,percent of total billed charges,,,60,,273.6,percent of total billed charges,,273.6,433.2,
ER 20605 ARTHROCENT/ASP/INJ INT JNT WO US,4504239,CDM,450,RC,20605,CPT,,,Inpatient,,,456,,,,80,,364.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,354.31,percent of total billed charges,,,95,,433.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,433.2,
ER 20610 DRN/INJ MAJOR JOINT/BURSA WO US,4504247,CDM,450,RC,20610,CPT,,,Outpatient,,,536,,,,80,,428.8,percent of total billed charges,,,,50,165.27,fee schedule,,,77.7,,416.47,percent of total billed charges,,,95,,509.2,percent of total billed charges,,,60,,321.6,percent of total billed charges,,321.6,509.2,
ER 20610 DRN/INJ MAJOR JOINT/BURSA WO US,4504247,CDM,450,RC,20610,CPT,,,Inpatient,,,536,,,,80,,428.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,416.47,percent of total billed charges,,,95,,509.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,509.2,
ER 94640 PRESSURIZED/NOPRESS INHAL TRMT,4504296,CDM,450,RC,94640,CPT,,,Outpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,50,20.89,fee schedule,,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,60,,157.06,percent of total billed charges,,157.06,248.68,
ER 94640 PRESSURIZED/NOPRESS INHAL TRMT,4504296,CDM,450,RC,94640,CPT,,,Inpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,248.68,
ER 24640 CLSD TRMT RADIAL HD SBLUX CHILD,4504353,CDM,450,RC,24640,CPT,,,Outpatient,,,1271,,,,80,,1016.8,percent of total billed charges,,,,50,404.51,fee schedule,,,77.7,,987.57,percent of total billed charges,,,95,,1207.45,percent of total billed charges,,,60,,762.6,percent of total billed charges,,762.6,1207.45,
ER 24640 CLSD TRMT RADIAL HD SBLUX CHILD,4504353,CDM,450,RC,24640,CPT,,,Inpatient,,,1271,,,,80,,1016.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,987.57,percent of total billed charges,,,95,,1207.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1207.45,
ER 23650  CLSD TRMT SHOULDER DISCLOC W/MNP,4504395,CDM,450,RC,23650,CPT,,,Outpatient,,,1409,,,,80,,1127.2,percent of total billed charges,,,,50,448.95,fee schedule,,,77.7,,1094.79,percent of total billed charges,,,95,,1338.55,percent of total billed charges,,,60,,845.4,percent of total billed charges,,845.4,1338.55,
ER 23650  CLSD TRMT SHOULDER DISCLOC W/MNP,4504395,CDM,450,RC,23650,CPT,,,Inpatient,,,1409,,,,80,,1127.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1094.79,percent of total billed charges,,,95,,1338.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1338.55,
ER 11730 AVULSN NAIL PLATE PART/COM SIMP,4504411,CDM,450,RC,11730,CPT,,,Outpatient,,,243,,,,80,,194.4,percent of total billed charges,,,,50,108.86,fee schedule,,,77.7,,188.81,percent of total billed charges,,,95,,230.85,percent of total billed charges,,,60,,145.8,percent of total billed charges,,145.8,230.85,
ER 11730 AVULSN NAIL PLATE PART/COM SIMP,4504411,CDM,450,RC,11730,CPT,,,Inpatient,,,243,,,,80,,194.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,188.81,percent of total billed charges,,,95,,230.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,230.85,
ER 31500 INTUBATION,4504445,CDM,450,RC,31500,CPT,,,Outpatient,,,396,,,,80,,316.8,percent of total billed charges,,,,85,336.6,percent of total billed charges,,,77.7,,307.69,percent of total billed charges,,,95,,376.2,percent of total billed charges,,,60,,237.6,percent of total billed charges,,237.6,376.2,
ER 31500 INTUBATION,4504445,CDM,450,RC,31500,CPT,,,Inpatient,,,396,,,,80,,316.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,307.69,percent of total billed charges,,,95,,376.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,376.2,
ER 29130 APPLICATION OF FINGER SPLINT,4504452,CDM,450,RC,29130,CPT,,,Outpatient,,,323,,,,80,,258.4,percent of total billed charges,,,,50,115.14,fee schedule,,,77.7,,250.97,percent of total billed charges,,,95,,306.85,percent of total billed charges,,,60,,193.8,percent of total billed charges,,193.8,306.85,
ER 29130 APPLICATION OF FINGER SPLINT,4504452,CDM,450,RC,29130,CPT,,,Inpatient,,,323,,,,80,,258.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,250.97,percent of total billed charges,,,95,,306.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,306.85,
ER 29105 APPLY LONG ARM SPLINT,4504494,CDM,450,RC,29105,CPT,,,Outpatient,,,337,,,,80,,269.6,percent of total billed charges,,,,50,115.14,fee schedule,,,77.7,,261.85,percent of total billed charges,,,95,,320.15,percent of total billed charges,,,60,,202.2,percent of total billed charges,,202.2,320.15,
ER 29105 APPLY LONG ARM SPLINT,4504494,CDM,450,RC,29105,CPT,,,Inpatient,,,337,,,,80,,269.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,261.85,percent of total billed charges,,,95,,320.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,320.15,
ER 29125 APPLY FOREARM SPLINT,4504502,CDM,450,RC,29125,CPT,,,Outpatient,,,325,,,,80,,260,percent of total billed charges,,,,50,115.14,fee schedule,,,77.7,,252.53,percent of total billed charges,,,95,,308.75,percent of total billed charges,,,60,,195,percent of total billed charges,,195,308.75,
ER 29125 APPLY FOREARM SPLINT,4504502,CDM,450,RC,29125,CPT,,,Inpatient,,,325,,,,80,,260,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,252.53,percent of total billed charges,,,95,,308.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,308.75,
ER 29515 APPLICATION LOWER LEG SPLINT,4504551,CDM,450,RC,29515,CPT,,,Outpatient,,,348,,,,80,,278.4,percent of total billed charges,,,,50,115.14,fee schedule,,,77.7,,270.4,percent of total billed charges,,,95,,330.6,percent of total billed charges,,,60,,208.8,percent of total billed charges,,208.8,330.6,
ER 29515 APPLICATION LOWER LEG SPLINT,4504551,CDM,450,RC,29515,CPT,,,Inpatient,,,348,,,,80,,278.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,270.4,percent of total billed charges,,,95,,330.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,330.6,
ER 10120 I&R FRGN BODY SUBCU TISS SIMPLE,4504627,CDM,450,RC,10120,CPT,,,Outpatient,,,1371,,,,80,,1096.8,percent of total billed charges,,,,50,537.83,fee schedule,,,77.7,,1065.27,percent of total billed charges,,,95,,1302.45,percent of total billed charges,,,60,,822.6,percent of total billed charges,,822.6,1302.45,
ER 10120 I&R FRGN BODY SUBCU TISS SIMPLE,4504627,CDM,450,RC,10120,CPT,,,Inpatient,,,1371,,,,80,,1096.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1065.27,percent of total billed charges,,,95,,1302.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1302.45,
ER 12001 SIMPLE RPR STHF 2.5CM OR LESS,4504635,CDM,450,RC,12001,CPT,,,Outpatient,,,488,,,,80,,390.4,percent of total billed charges,,,,50,191.4,fee schedule,,,77.7,,379.18,percent of total billed charges,,,95,,463.6,percent of total billed charges,,,60,,292.8,percent of total billed charges,,292.8,463.6,
ER 12001 SIMPLE RPR STHF 2.5CM OR LESS,4504635,CDM,450,RC,12001,CPT,,,Inpatient,,,488,,,,80,,390.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,379.18,percent of total billed charges,,,95,,463.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,463.6,
ER 12002 SIMPLE RPR STHF 2.6CM-7.5CM,4504643,CDM,450,RC,12002,CPT,,,Outpatient,,,574,,,,80,,459.2,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,446,percent of total billed charges,,,95,,545.3,percent of total billed charges,,,60,,344.4,percent of total billed charges,,344.4,545.3,
ER 12002 SIMPLE RPR STHF 2.6CM-7.5CM,4504643,CDM,450,RC,12002,CPT,,,Inpatient,,,574,,,,80,,459.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,446,percent of total billed charges,,,95,,545.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,545.3,
ER 12004 SIMPLE RPR STHF 7.6CM-12.5CM,4504650,CDM,450,RC,12004,CPT,,,Outpatient,,,725,,,,80,,580,percent of total billed charges,,,,50,288.86,fee schedule,,,77.7,,563.33,percent of total billed charges,,,95,,688.75,percent of total billed charges,,,60,,435,percent of total billed charges,,435,688.75,
ER 12004 SIMPLE RPR STHF 7.6CM-12.5CM,4504650,CDM,450,RC,12004,CPT,,,Inpatient,,,725,,,,80,,580,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,563.33,percent of total billed charges,,,95,,688.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,688.75,
ER 12005 SIMPLE RPR STHF 12.6-20CM,4504668,CDM,450,RC,12005,CPT,,,Outpatient,,,1500,,,,80,,1200,percent of total billed charges,,,,50,404.51,fee schedule,,,77.7,,1165.5,percent of total billed charges,,,95,,1425,percent of total billed charges,,,60,,900,percent of total billed charges,,900,1425,
ER 12005 SIMPLE RPR STHF 12.6-20CM,4504668,CDM,450,RC,12005,CPT,,,Inpatient,,,1500,,,,80,,1200,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1165.5,percent of total billed charges,,,95,,1425,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1425,
ER 12011 SIMPLE RPR FACE 2.5CM OR LESS,4504676,CDM,450,RC,12011,CPT,,,Outpatient,,,597,,,,80,,477.6,percent of total billed charges,,,,50,237.86,fee schedule,,,77.7,,463.87,percent of total billed charges,,,95,,567.15,percent of total billed charges,,,60,,358.2,percent of total billed charges,,358.2,567.15,
ER 12011 SIMPLE RPR FACE 2.5CM OR LESS,4504676,CDM,450,RC,12011,CPT,,,Inpatient,,,597,,,,80,,477.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,463.87,percent of total billed charges,,,95,,567.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,567.15,
ER 12013 REPAIR SIMP FEL 2.6CM-5.0CM,4504684,CDM,450,RC,12013,CPT,,,Outpatient,,,597,,,,80,,477.6,percent of total billed charges,,,,50,237.86,fee schedule,,,77.7,,463.87,percent of total billed charges,,,95,,567.15,percent of total billed charges,,,60,,358.2,percent of total billed charges,,358.2,567.15,
ER 12013 REPAIR SIMP FEL 2.6CM-5.0CM,4504684,CDM,450,RC,12013,CPT,,,Inpatient,,,597,,,,80,,477.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,463.87,percent of total billed charges,,,95,,567.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,567.15,
ER 30901 CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE,4504759,CDM,450,RC,30901,CPT,,,Outpatient,,,615,,,,80,,492,percent of total billed charges,,,,50,244.42,fee schedule,,,77.7,,477.86,percent of total billed charges,,,95,,584.25,percent of total billed charges,,,60,,369,percent of total billed charges,,369,584.25,
ER 30901 CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE,4504759,CDM,450,RC,30901,CPT,,,Inpatient,,,615,,,,80,,492,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,477.86,percent of total billed charges,,,95,,584.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,584.25,
ER 69210 REMOVE IMPACT EAR WAX W INSTRMT,4504767,CDM,450,RC,69210,CPT,,,Outpatient,,,583,,,,80,,466.4,percent of total billed charges,,,,50,271.66,fee schedule,,,77.7,,452.99,percent of total billed charges,,,95,,553.85,percent of total billed charges,,,60,,349.8,percent of total billed charges,,349.8,553.85,
ER 69210 REMOVE IMPACT EAR WAX W INSTRMT,4504767,CDM,450,RC,69210,CPT,,,Inpatient,,,583,,,,80,,466.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,452.99,percent of total billed charges,,,95,,553.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,553.85,
ER 12006 RPR SIMP S/N/A/GN/TRK20.1-30.0CM,4504791,CDM,450,RC,12006,CPT,,,Outpatient,,,2020,,,,80,,1616,percent of total billed charges,,,,50,769.12,fee schedule,,,77.7,,1569.54,percent of total billed charges,,,95,,1919,percent of total billed charges,,,60,,1212,percent of total billed charges,,1212,1919,
ER 12006 RPR SIMP S/N/A/GN/TRK20.1-30.0CM,4504791,CDM,450,RC,12006,CPT,,,Inpatient,,,2020,,,,80,,1616,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1569.54,percent of total billed charges,,,95,,1919,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1919,
ER 12032 REPAIR INTER SATE 2.6-7.5CM,4504858,CDM,450,RC,12032,CPT,,,Outpatient,,,1675,,,,80,,1340,percent of total billed charges,,,,50,225.59,fee schedule,,,77.7,,1301.48,percent of total billed charges,,,95,,1591.25,percent of total billed charges,,,60,,1005,percent of total billed charges,,1005,1591.25,
ER 12032 REPAIR INTER SATE 2.6-7.5CM,4504858,CDM,450,RC,12032,CPT,,,Inpatient,,,1675,,,,80,,1340,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1301.48,percent of total billed charges,,,95,,1591.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1591.25,
ER 12035 INTMD RPR S/A/T/EXT 12.6-20,4504874,CDM,450,RC,12035,CPT,,,Outpatient,,,2300,,,,80,,1840,percent of total billed charges,,,,50,912.03,fee schedule,,,77.7,,1787.1,percent of total billed charges,,,95,,2185,percent of total billed charges,,,60,,1380,percent of total billed charges,,1380,2185,
ER 12035 INTMD RPR S/A/T/EXT 12.6-20,4504874,CDM,450,RC,12035,CPT,,,Inpatient,,,2300,,,,80,,1840,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1787.1,percent of total billed charges,,,95,,2185,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2185,
ER 12042 INTMD RPR N-HF/GENIT2.6-7.5,4504908,CDM,450,RC,12042,CPT,,,Outpatient,,,2155,,,,80,,1724,percent of total billed charges,,,,50,353.5,fee schedule,,,77.7,,1674.44,percent of total billed charges,,,95,,2047.25,percent of total billed charges,,,60,,1293,percent of total billed charges,,1293,2047.25,
ER 12042 INTMD RPR N-HF/GENIT2.6-7.5,4504908,CDM,450,RC,12042,CPT,,,Inpatient,,,2155,,,,80,,1724,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1674.44,percent of total billed charges,,,95,,2047.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2047.25,
ER 12053 INTMD RPR FACE/MM 5.1-7.5 CM,4504932,CDM,450,RC,12053,CPT,,,Outpatient,,,1225,,,,80,,980,percent of total billed charges,,,,50,486.82,fee schedule,,,77.7,,951.83,percent of total billed charges,,,95,,1163.75,percent of total billed charges,,,60,,735,percent of total billed charges,,735,1163.75,
ER 12053 INTMD RPR FACE/MM 5.1-7.5 CM,4504932,CDM,450,RC,12053,CPT,,,Inpatient,,,1225,,,,80,,980,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,951.83,percent of total billed charges,,,95,,1163.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1163.75,
ER 10061 INCIS & DRAIN ABSCESS COMP,4505053,CDM,450,RC,10061,CPT,,,Outpatient,,,2064,,,,80,,1651.2,percent of total billed charges,,,,50,742.35,fee schedule,,,77.7,,1603.73,percent of total billed charges,,,95,,1960.8,percent of total billed charges,,,60,,1238.4,percent of total billed charges,,1238.4,1960.8,
ER 10061 INCIS & DRAIN ABSCESS COMP,4505053,CDM,450,RC,10061,CPT,,,Inpatient,,,2064,,,,80,,1651.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1603.73,percent of total billed charges,,,95,,1960.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1960.8,
ER 10080 INCIS & DRAIN PILONIDAL CYST S,4505061,CDM,450,RC,10080,CPT,,,Outpatient,,,1253,,,,80,,1002.4,percent of total billed charges,,,,50,491.37,fee schedule,,,77.7,,973.58,percent of total billed charges,,,95,,1190.35,percent of total billed charges,,,60,,751.8,percent of total billed charges,,751.8,1190.35,
ER 10080 INCIS & DRAIN PILONIDAL CYST S,4505061,CDM,450,RC,10080,CPT,,,Inpatient,,,1253,,,,80,,1002.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,973.58,percent of total billed charges,,,95,,1190.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1190.35,
ER 16020 DRESS/DEBRID  BURN SM < 5%,4505327,CDM,450,RC,16020,CPT,,,Outpatient,,,540,,,,80,,432,percent of total billed charges,,,,50,185.84,fee schedule,,,77.7,,419.58,percent of total billed charges,,,95,,513,percent of total billed charges,,,60,,324,percent of total billed charges,,324,513,
ER 16020 DRESS/DEBRID  BURN SM < 5%,4505327,CDM,450,RC,16020,CPT,,,Inpatient,,,540,,,,80,,432,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,419.58,percent of total billed charges,,,95,,513,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,513,
ER 25605 CLSD TRMT DISTAL RADIAL W MAN,4505657,CDM,450,RC,25605,CPT,,,Outpatient,,,1799,,,,80,,1439.2,percent of total billed charges,,,,50,717.1,fee schedule,,,77.7,,1397.82,percent of total billed charges,,,95,,1709.05,percent of total billed charges,,,60,,1079.4,percent of total billed charges,,1079.4,1709.05,
ER 25605 CLSD TRMT DISTAL RADIAL W MAN,4505657,CDM,450,RC,25605,CPT,,,Inpatient,,,1799,,,,80,,1439.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1397.82,percent of total billed charges,,,95,,1709.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1709.05,
ER 26725 CLSD TRMT FINGER SHAFT W OR WO,4505749,CDM,450,RC,26725,CPT,,,Outpatient,,,1572,,,,80,,1257.6,percent of total billed charges,,,,50,568.63,fee schedule,,,77.7,,1221.44,percent of total billed charges,,,95,,1493.4,percent of total billed charges,,,60,,943.2,percent of total billed charges,,943.2,1493.4,
ER 26725 CLSD TRMT FINGER SHAFT W OR WO,4505749,CDM,450,RC,26725,CPT,,,Inpatient,,,1572,,,,80,,1257.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1221.44,percent of total billed charges,,,95,,1493.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1493.4,
ER 29505 SPLINT APPL LONG LEG,4506341,CDM,450,RC,29505,CPT,,,Outpatient,,,391,,,,80,,312.8,percent of total billed charges,,,,50,115.14,fee schedule,,,77.7,,303.81,percent of total billed charges,,,95,,371.45,percent of total billed charges,,,60,,234.6,percent of total billed charges,,234.6,371.45,
ER 29505 SPLINT APPL LONG LEG,4506341,CDM,450,RC,29505,CPT,,,Inpatient,,,391,,,,80,,312.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,303.81,percent of total billed charges,,,95,,371.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,371.45,
ER 32555 ASPIRATE PLEURA WITH IMAGING,4506457,CDM,450,RC,32555,CPT,,,Outpatient,,,1256,,,,80,,1004.8,percent of total billed charges,,,,50,431.27,fee schedule,,,77.7,,975.91,percent of total billed charges,,,95,,1193.2,percent of total billed charges,,,60,,753.6,percent of total billed charges,,753.6,1193.2,
ER 32555 ASPIRATE PLEURA WITH IMAGING,4506457,CDM,450,RC,32555,CPT,,,Inpatient,,,1256,,,,80,,1004.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,975.91,percent of total billed charges,,,95,,1193.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1193.2,
ER 36556 INSERT NT CV CATH 5+,4506465,CDM,450,RC,36556,CPT,,,Outpatient,,,3400,,,,80,,2720,percent of total billed charges,,,,50,1333.2,fee schedule,,,77.7,,2641.8,percent of total billed charges,,,95,,3230,percent of total billed charges,,,60,,2040,percent of total billed charges,,2040,3230,
ER 36556 INSERT NT CV CATH 5+,4506465,CDM,450,RC,36556,CPT,,,Inpatient,,,3400,,,,80,,2720,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2641.8,percent of total billed charges,,,95,,3230,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3230,
ER 62270 SPINAL PUNCTURE LUMBAR DIAG,4506762,CDM,450,RC,62270,CPT,,,Outpatient,,,911,,,,80,,728.8,percent of total billed charges,,,,50,216.65,fee schedule,,,77.7,,707.85,percent of total billed charges,,,95,,865.45,percent of total billed charges,,,60,,546.6,percent of total billed charges,,546.6,865.45,
ER 62270 SPINAL PUNCTURE LUMBAR DIAG,4506762,CDM,450,RC,62270,CPT,,,Inpatient,,,911,,,,80,,728.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,707.85,percent of total billed charges,,,95,,865.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,865.45,
ER 64450 INJ ANES AGENT OTHR PERIPH NRV,4506812,CDM,450,RC,64450,CPT,,,Outpatient,,,1080,,,,80,,864,percent of total billed charges,,,,50,429.76,fee schedule,,,77.7,,839.16,percent of total billed charges,,,95,,1026,percent of total billed charges,,,60,,648,percent of total billed charges,,648,1026,
ER 64450 INJ ANES AGENT OTHR PERIPH NRV,4506812,CDM,450,RC,64450,CPT,,,Inpatient,,,1080,,,,80,,864,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,839.16,percent of total billed charges,,,95,,1026,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1026,
ER 65220 REM FRGN BODY CORNEAL WO LAMP,4506853,CDM,450,RC,65220,CPT,,,Outpatient,,,757,,,,80,,605.6,percent of total billed charges,,,,50,270.68,fee schedule,,,77.7,,588.19,percent of total billed charges,,,95,,719.15,percent of total billed charges,,,60,,454.2,percent of total billed charges,,454.2,719.15,
ER 65220 REM FRGN BODY CORNEAL WO LAMP,4506853,CDM,450,RC,65220,CPT,,,Inpatient,,,757,,,,80,,605.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,588.19,percent of total billed charges,,,95,,719.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,719.15,
ER 29126 APPLY SPLINT SHORT ARM DYNAMIC,4507018,CDM,450,RC,29126,CPT,,,Outpatient,,,323,,,,80,,258.4,percent of total billed charges,,,,50,115.14,fee schedule,,,77.7,,250.97,percent of total billed charges,,,95,,306.85,percent of total billed charges,,,60,,193.8,percent of total billed charges,,193.8,306.85,
ER 29126 APPLY SPLINT SHORT ARM DYNAMIC,4507018,CDM,450,RC,29126,CPT,,,Inpatient,,,323,,,,80,,258.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,250.97,percent of total billed charges,,,95,,306.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,306.85,
ER 26010 DRAINAGE OF FINGER ABSCESS SIMP,4507117,CDM,450,RC,26010,CPT,,,Outpatient,,,402,,,,80,,321.6,percent of total billed charges,,,,50,160.09,fee schedule,,,77.7,,312.35,percent of total billed charges,,,95,,381.9,percent of total billed charges,,,60,,241.2,percent of total billed charges,,241.2,381.9,
ER 26010 DRAINAGE OF FINGER ABSCESS SIMP,4507117,CDM,450,RC,26010,CPT,,,Inpatient,,,402,,,,80,,321.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,312.35,percent of total billed charges,,,95,,381.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,381.9,
"ER 37195 Thrombolysis, cerebral, by intravenous infusion",4507265,CDM,450,RC,37195,CPT,,,Outpatient,,,325,,,,80,,260,percent of total billed charges,,,,85,276.25,percent of total billed charges,,,77.7,,252.53,percent of total billed charges,,,95,,308.75,percent of total billed charges,,,60,,195,percent of total billed charges,,195,308.75,
"ER 37195 Thrombolysis, cerebral, by intravenous infusion",4507265,CDM,450,RC,37195,CPT,,,Inpatient,,,325,,,,80,,260,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,252.53,percent of total billed charges,,,95,,308.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,308.75,
PF Spirometry Evaluation,4600029,CDM,460,RC,94010,CPT,,,Outpatient,,,540,,,,80,,432,percent of total billed charges,,,,50,150.49,fee schedule,,,77.7,,419.58,percent of total billed charges,,,95,,513,percent of total billed charges,,,60,,324,percent of total billed charges,,324,513,
PF Spirometry Evaluation,4600029,CDM,460,RC,94010,CPT,,,Inpatient,,,540,,,,80,,432,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,419.58,percent of total billed charges,,,95,,513,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,513,
PF Bronchodilation Responsiveness,4600060,CDM,460,RC,94060,CPT,,,Outpatient,,,406,,,,80,,324.8,percent of total billed charges,,,,50,148.66,fee schedule,,,77.7,,315.46,percent of total billed charges,,,95,,385.7,percent of total billed charges,,,60,,243.6,percent of total billed charges,,243.6,385.7,
PF Bronchodilation Responsiveness,4600060,CDM,460,RC,94060,CPT,,,Inpatient,,,406,,,,80,,324.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,315.46,percent of total billed charges,,,95,,385.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,385.7,
PF GAS DILUTION OR WASHOUT,4600573,CDM,460,RC,94727,CPT,,,Outpatient,,,376,,,,80,,300.8,percent of total billed charges,,,,50,46.92,fee schedule,,,77.7,,292.15,percent of total billed charges,,,95,,357.2,percent of total billed charges,,,60,,225.6,percent of total billed charges,,225.6,357.2,
PF GAS DILUTION OR WASHOUT,4600573,CDM,460,RC,94727,CPT,,,Inpatient,,,376,,,,80,,300.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,292.15,percent of total billed charges,,,95,,357.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,357.2,
PF Diffusing Capacity Co/Membrane,4600581,CDM,460,RC,94729,CPT,,,Outpatient,,,219,,,,80,,175.2,percent of total billed charges,,,,50,59.27,fee schedule,,,77.7,,170.16,percent of total billed charges,,,95,,208.05,percent of total billed charges,,,60,,131.4,percent of total billed charges,,131.4,208.05,
PF Diffusing Capacity Co/Membrane,4600581,CDM,460,RC,94729,CPT,,,Inpatient,,,219,,,,80,,175.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,170.16,percent of total billed charges,,,95,,208.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,208.05,
PF Exercise Tst Brncspsm,4600649,CDM,460,RC,94617,CPT,,,Outpatient,,,419,,,,80,,335.2,percent of total billed charges,,,,85,356.15,percent of total billed charges,,,77.7,,325.56,percent of total billed charges,,,95,,398.05,percent of total billed charges,,,60,,251.4,percent of total billed charges,,251.4,398.05,
PF Exercise Tst Brncspsm,4600649,CDM,460,RC,94617,CPT,,,Inpatient,,,419,,,,80,,335.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,325.56,percent of total billed charges,,,95,,398.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,398.05,
PF Pulmonary Stress Testing,4600656,CDM,460,RC,94618,CPT,,,Outpatient,,,193,,,,80,,154.4,percent of total billed charges,,,,50,62.12,fee schedule,,,77.7,,149.96,percent of total billed charges,,,95,,183.35,percent of total billed charges,,,60,,115.8,percent of total billed charges,,115.8,183.35,
PF Pulmonary Stress Testing,4600656,CDM,460,RC,94618,CPT,,,Inpatient,,,193,,,,80,,154.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,149.96,percent of total billed charges,,,95,,183.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,183.35,
"Hearing Test Performed Date, Time",4700290,CDM,470,RC,92587,CPT,,,Outpatient,,,271,,,,80,,216.8,percent of total billed charges,,,,50,28.17,fee schedule,,,77.7,,210.57,percent of total billed charges,,,95,,257.45,percent of total billed charges,,,60,,162.6,percent of total billed charges,,162.6,257.45,
"Hearing Test Performed Date, Time",4700290,CDM,470,RC,92587,CPT,,,Inpatient,,,271,,,,80,,216.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,210.57,percent of total billed charges,,,95,,257.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,257.45,
Exercise Stress Test 93017,4800058,CDM,482,RC,93017,CPT,,,Outpatient,,,575,,,,80,,460,percent of total billed charges,,,,50,178.19,fee schedule,,,77.7,,446.78,percent of total billed charges,,,95,,546.25,percent of total billed charges,,,60,,345,percent of total billed charges,,345,546.25,
Lexiscan Stress Test 93017,4800058,CDM,482,RC,93017,CPT,,,Outpatient,,,575,,,,80,,460,percent of total billed charges,,,,50,178.19,fee schedule,,,77.7,,446.78,percent of total billed charges,,,95,,546.25,percent of total billed charges,,,60,,345,percent of total billed charges,,345,546.25,
Stress Test (Resp),4800058,CDM,482,RC,93017,CPT,,,Outpatient,,,575,,,,80,,460,percent of total billed charges,,,,50,178.19,fee schedule,,,77.7,,446.78,percent of total billed charges,,,95,,546.25,percent of total billed charges,,,60,,345,percent of total billed charges,,345,546.25,
Stress Test Trace Only WO Int & Rpt,4800058,CDM,482,RC,93017,CPT,,,Outpatient,,,575,,,,80,,460,percent of total billed charges,,,,50,178.19,fee schedule,,,77.7,,446.78,percent of total billed charges,,,95,,546.25,percent of total billed charges,,,60,,345,percent of total billed charges,,345,546.25,
Exercise Stress Test 93017,4800058,CDM,482,RC,93017,CPT,,,Inpatient,,,575,,,,80,,460,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,446.78,percent of total billed charges,,,95,,546.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,546.25,
Lexiscan Stress Test 93017,4800058,CDM,482,RC,93017,CPT,,,Inpatient,,,575,,,,80,,460,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,446.78,percent of total billed charges,,,95,,546.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,546.25,
Stress Test (Resp),4800058,CDM,482,RC,93017,CPT,,,Inpatient,,,575,,,,80,,460,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,446.78,percent of total billed charges,,,95,,546.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,546.25,
Stress Test Trace Only WO Int & Rpt,4800058,CDM,482,RC,93017,CPT,,,Inpatient,,,575,,,,80,,460,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,446.78,percent of total billed charges,,,95,,546.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,546.25,
MRI Face Neck Orbit w/o Contrast,6100028,CDM,610,RC,70540,CPT,,,Outpatient,,,1300,,,,80,,1040,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1010.1,percent of total billed charges,,,95,,1235,percent of total billed charges,,,60,,780,percent of total billed charges,,780,1235,
MRI Face Neck Orbit w/o Contrast,6100028,CDM,610,RC,70540,CPT,,,Inpatient,,,1300,,,,80,,1040,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1010.1,percent of total billed charges,,,95,,1235,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1235,
MRI Pelvis w/ Contrast,6100044,CDM,610,RC,72196,CPT,,,Outpatient,,,1375,,,,80,,1100,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1068.38,percent of total billed charges,,,95,,1306.25,percent of total billed charges,,,60,,825,percent of total billed charges,,825,1306.25,
MRI Pelvis w/ Contrast,6100044,CDM,610,RC,72196,CPT,,,Inpatient,,,1375,,,,80,,1100,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1068.38,percent of total billed charges,,,95,,1306.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1306.25,
MRI UE Joint w/o Contrast Left,6100069,CDM,610,RC,73221,CPT,,,Outpatient,,,1250,,,,80,,1000,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,971.25,percent of total billed charges,,,95,,1187.5,percent of total billed charges,,,60,,750,percent of total billed charges,,750,1187.5,
MRI UE Joint w/o Contrast Left,6100069,CDM,610,RC,73221,CPT,,,Inpatient,,,1250,,,,80,,1000,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,971.25,percent of total billed charges,,,95,,1187.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1187.5,
MRI LE Joint w/o Contrast Bilateral,6100085,CDM,610,RC,73721,CPT,,,Outpatient,,,1300,,,,80,,1040,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1010.1,percent of total billed charges,,,95,,1235,percent of total billed charges,,,60,,780,percent of total billed charges,,780,1235,
MRI LE Joint w/o Contrast Bilateral,6100085,CDM,610,RC,73721,CPT,,,Inpatient,,,1300,,,,80,,1040,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1010.1,percent of total billed charges,,,95,,1235,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1235,
MRI Abdomen w/o Contrast,6100093,CDM,610,RC,74181,CPT,,,Outpatient,,,1600,,,,80,,1280,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1243.2,percent of total billed charges,,,95,,1520,percent of total billed charges,,,60,,960,percent of total billed charges,,960,1520,
MRI Abdomen w/o Contrast,6100093,CDM,610,RC,74181,CPT,,,Inpatient,,,1600,,,,80,,1280,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1243.2,percent of total billed charges,,,95,,1520,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1520,
MRI Brain w/o Contrast,6100143,CDM,610,RC,70551,CPT,,,Outpatient,,,1463,,,,80,,1170.4,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1136.75,percent of total billed charges,,,95,,1389.85,percent of total billed charges,,,60,,877.8,percent of total billed charges,,877.8,1389.85,
MRI Brain w/o Contrast,6100143,CDM,610,RC,70551,CPT,,,Inpatient,,,1463,,,,80,,1170.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1136.75,percent of total billed charges,,,95,,1389.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1389.85,
MRI Brain w/ + w/o Contrast,6100168,CDM,610,RC,70553,CPT,,,Outpatient,,,1830,,,,80,,1464,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1421.91,percent of total billed charges,,,95,,1738.5,percent of total billed charges,,,60,,1098,percent of total billed charges,,1098,1738.5,
MRI Brain w/ + w/o Contrast,6100168,CDM,610,RC,70553,CPT,,,Inpatient,,,1830,,,,80,,1464,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1421.91,percent of total billed charges,,,95,,1738.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1738.5,
MRI Spine Cervical w/o Contrast,6100176,CDM,610,RC,72141,CPT,,,Outpatient,,,1376,,,,80,,1100.8,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1069.15,percent of total billed charges,,,95,,1307.2,percent of total billed charges,,,60,,825.6,percent of total billed charges,,825.6,1307.2,
MRI Spine Cervical w/o Contrast,6100176,CDM,610,RC,72141,CPT,,,Inpatient,,,1376,,,,80,,1100.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1069.15,percent of total billed charges,,,95,,1307.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1307.2,
MRI Spine Thoracic w/o Contrast,6100192,CDM,610,RC,72146,CPT,,,Outpatient,,,1413,,,,80,,1130.4,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1097.9,percent of total billed charges,,,95,,1342.35,percent of total billed charges,,,60,,847.8,percent of total billed charges,,847.8,1342.35,
MRI Spine Thoracic w/o Contrast,6100192,CDM,610,RC,72146,CPT,,,Inpatient,,,1413,,,,80,,1130.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1097.9,percent of total billed charges,,,95,,1342.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1342.35,
MRI Spine Lumbar w/o Contrast,6100218,CDM,610,RC,72148,CPT,,,Outpatient,,,1424,,,,80,,1139.2,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1106.45,percent of total billed charges,,,95,,1352.8,percent of total billed charges,,,60,,854.4,percent of total billed charges,,854.4,1352.8,
MRI Spine Lumbar w/o Contrast,6100218,CDM,610,RC,72148,CPT,,,Inpatient,,,1424,,,,80,,1139.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1106.45,percent of total billed charges,,,95,,1352.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1352.8,
MRI Spine Thoracic w/ + w/o Contrast,6100242,CDM,610,RC,72157,CPT,,,Outpatient,,,1668,,,,80,,1334.4,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1296.04,percent of total billed charges,,,95,,1584.6,percent of total billed charges,,,60,,1000.8,percent of total billed charges,,1000.8,1584.6,
MRI Spine Thoracic w/ + w/o Contrast,6100242,CDM,610,RC,72157,CPT,,,Inpatient,,,1668,,,,80,,1334.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1296.04,percent of total billed charges,,,95,,1584.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1584.6,
MRI Spine Lumbar w/ + w/o Contrast,6100259,CDM,610,RC,72158,CPT,,,Outpatient,,,1668,,,,80,,1334.4,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1296.04,percent of total billed charges,,,95,,1584.6,percent of total billed charges,,,60,,1000.8,percent of total billed charges,,1000.8,1584.6,
MRI Spine Lumbar w/ + w/o Contrast,6100259,CDM,610,RC,72158,CPT,,,Inpatient,,,1668,,,,80,,1334.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1296.04,percent of total billed charges,,,95,,1584.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1584.6,
MRI Face Neck Orbit w/ Contrast,6100416,CDM,610,RC,70542,CPT,,,Outpatient,,,1375,,,,80,,1100,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1068.38,percent of total billed charges,,,95,,1306.25,percent of total billed charges,,,60,,825,percent of total billed charges,,825,1306.25,
MRI Face Neck Orbit w/ Contrast,6100416,CDM,610,RC,70542,CPT,,,Inpatient,,,1375,,,,80,,1100,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1068.38,percent of total billed charges,,,95,,1306.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1306.25,
MRI Pelvis w/o Contrast,6100515,CDM,610,RC,72195,CPT,,,Outpatient,,,1250,,,,80,,1000,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,971.25,percent of total billed charges,,,95,,1187.5,percent of total billed charges,,,60,,750,percent of total billed charges,,750,1187.5,
MRI Pelvis w/o Contrast,6100515,CDM,610,RC,72195,CPT,,,Inpatient,,,1250,,,,80,,1000,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,971.25,percent of total billed charges,,,95,,1187.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1187.5,
MRI Pelvis w/ + w/o Contrast,6100523,CDM,610,RC,72197,CPT,,,Outpatient,,,1600,,,,80,,1280,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1243.2,percent of total billed charges,,,95,,1520,percent of total billed charges,,,60,,960,percent of total billed charges,,960,1520,
MRI Pelvis w/ + w/o Contrast,6100523,CDM,610,RC,72197,CPT,,,Inpatient,,,1600,,,,80,,1280,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1243.2,percent of total billed charges,,,95,,1520,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1520,
MRI UE Non Joint w/o Contrast Left,6100531,CDM,610,RC,73218,CPT,,,Outpatient,,,1300,,,,80,,1040,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1010.1,percent of total billed charges,,,95,,1235,percent of total billed charges,,,60,,780,percent of total billed charges,,780,1235,
MRI UE Non Joint w/o Contrast Left,6100531,CDM,610,RC,73218,CPT,,,Inpatient,,,1300,,,,80,,1040,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1010.1,percent of total billed charges,,,95,,1235,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1235,
MRI LE Non Joint w/o Contrast Bilat,6100572,CDM,610,RC,73718,CPT,,,Outpatient,,,1300,,,,80,,1040,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1010.1,percent of total billed charges,,,95,,1235,percent of total billed charges,,,60,,780,percent of total billed charges,,780,1235,
MRI LE Non Joint w/o Contrast Bilat,6100572,CDM,610,RC,73718,CPT,,,Inpatient,,,1300,,,,80,,1040,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1010.1,percent of total billed charges,,,95,,1235,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1235,
MRI Abdomen w/ + w/o Contrast,6100622,CDM,610,RC,74183,CPT,,,Outpatient,,,1740,,,,80,,1392,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1351.98,percent of total billed charges,,,95,,1653,percent of total billed charges,,,60,,1044,percent of total billed charges,,1044,1653,
MRI Abdomen w/ + w/o Contrast,6100622,CDM,610,RC,74183,CPT,,,Inpatient,,,1740,,,,80,,1392,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1351.98,percent of total billed charges,,,95,,1653,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1653,
dexamethasone 10 mg/mL Inj Sol 10 mL [KHKS],6192045,CDM,636,RC,J1100,HCPCS,67457-0483-10,NDC,Outpatient,10,ML,14.39,,,,80,,11.52,percent of total billed charges,,,,50,0.08,fee schedule,,,77.7,,11.18,percent of total billed charges,,,95,,13.67,percent of total billed charges,,,60,,8.64,percent of total billed charges,,0.08,13.67,
dexamethasone 10 mg/mL Inj Sol 10 mL [KHKS],6192045,CDM,636,RC,J1100,HCPCS,67457-0483-10,NDC,Inpatient,10,ML,14.39,,,,80,,11.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.18,percent of total billed charges,,,95,,13.67,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.67,
gadodiamide 287 mg/mL Inj Sol 15 mL [KHKS],6192046,CDM,636,RC,A9579,HCPCS,00407-0690-15,NDC,Outpatient,15,ML,75,,,,80,,60,percent of total billed charges,,,,50,4.75,fee schedule,,,77.7,,58.28,percent of total billed charges,,,95,,71.25,percent of total billed charges,,,60,,45,percent of total billed charges,,4.75,71.25,
gadodiamide 287 mg/mL Inj Sol 15 mL [KHKS],6192046,CDM,636,RC,A9579,HCPCS,00407-0690-15,NDC,Inpatient,15,ML,75,,,,80,,60,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,58.28,percent of total billed charges,,,95,,71.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,71.25,
sitaGLIPtin 50 mg oral tablet [KHKS],6192048,CDM,250,RC,00006-0112-28,NDC,,,Outpatient,1,EA,62.57,,,,80,,50.05,percent of total billed charges,,,,85,53.18,percent of total billed charges,,,77.7,,48.62,percent of total billed charges,,,95,,59.44,percent of total billed charges,,,60,,37.54,percent of total billed charges,,37.54,59.44,
sitaGLIPtin 50 mg oral tablet [KHKS],6192048,CDM,250,RC,00006-0112-28,NDC,,,Inpatient,1,EA,62.57,,,,80,,50.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,48.62,percent of total billed charges,,,95,,59.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,59.44,
aspirin 300 mg Supp [KHKS],6192049,CDM,250,RC,00574-7034-12,NDC,,,Outpatient,1,EA,4.37,,,,80,,3.5,percent of total billed charges,,,,85,3.71,percent of total billed charges,,,77.7,,3.4,percent of total billed charges,,,95,,4.16,percent of total billed charges,,,60,,2.62,percent of total billed charges,,2.62,4.16,
aspirin 300 mg Supp [KHKS],6192049,CDM,250,RC,00574-7034-12,NDC,,,Inpatient,1,EA,4.37,,,,80,,3.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.4,percent of total billed charges,,,95,,4.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.16,
dextromethorphan ER 30 mg/5 mL Oral Susp 148 mL [KHKS],6192050,CDM,250,RC,63824-0175-65,NDC,,,Outpatient,148,ML,70.98,,,,80,,56.78,percent of total billed charges,,,,85,60.33,percent of total billed charges,,,77.7,,55.15,percent of total billed charges,,,95,,67.43,percent of total billed charges,,,60,,42.59,percent of total billed charges,,42.59,67.43,
dextromethorphan ER 30 mg/5 mL Oral Susp 148 mL [KHKS],6192050,CDM,250,RC,63824-0175-65,NDC,,,Inpatient,148,ML,70.98,,,,80,,56.78,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,55.15,percent of total billed charges,,,95,,67.43,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,67.43,
verapamil 240 mg ER Tab [KHKS],6192051,CDM,250,RC,75834-0159-01,NDC,,,Outpatient,1,EA,4.91,,,,80,,3.93,percent of total billed charges,,,,85,4.17,percent of total billed charges,,,77.7,,3.81,percent of total billed charges,,,95,,4.66,percent of total billed charges,,,60,,2.94,percent of total billed charges,,2.94,4.66,
verapamil 240 mg ER Tab [KHKS],6192051,CDM,250,RC,75834-0159-01,NDC,,,Inpatient,1,EA,4.91,,,,80,,3.93,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.81,percent of total billed charges,,,95,,4.66,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.66,
valproic acid 100 mg/mL IV Sol 5 mL [KHKS],6192052,CDM,250,RC,00143-9637-10,NDC,,,Outpatient,5,ML,62.23,,,,80,,49.79,percent of total billed charges,,,,85,52.9,percent of total billed charges,,,77.7,,48.35,percent of total billed charges,,,95,,59.12,percent of total billed charges,,,60,,37.34,percent of total billed charges,,37.34,59.12,
valproic acid 100 mg/mL IV Sol 5 mL [KHKS],6192052,CDM,250,RC,00143-9637-10,NDC,,,Inpatient,5,ML,62.23,,,,80,,49.79,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,48.35,percent of total billed charges,,,95,,59.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,59.12,
latanoprost OPHTH 0.005% Sol 2.5 mL [KHKS],6192053,CDM,250,RC,61314-0547-01,NDC,,,Outpatient,2.5,EA,285,,,,80,,228,percent of total billed charges,,,,85,242.25,percent of total billed charges,,,77.7,,221.45,percent of total billed charges,,,95,,270.75,percent of total billed charges,,,60,,171,percent of total billed charges,,171,270.75,
latanoprost OPHTH 0.005% Sol 2.5 mL [KHKS],6192053,CDM,250,RC,61314-0547-01,NDC,,,Inpatient,2.5,EA,285,,,,80,,228,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,221.45,percent of total billed charges,,,95,,270.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,270.75,
digoxin 125 mcg (0.125 mg) Tab [KHKS],6192054,CDM,250,RC,16714-0590-01,NDC,,,Outpatient,1,EA,6.32,,,,80,,5.06,percent of total billed charges,,,,85,5.37,percent of total billed charges,,,77.7,,4.91,percent of total billed charges,,,95,,6,percent of total billed charges,,,60,,3.79,percent of total billed charges,,3.79,6,
digoxin 125 mcg (0.125 mg) Tab [KHKS],6192054,CDM,250,RC,16714-0590-01,NDC,,,Inpatient,1,EA,6.32,,,,80,,5.06,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.91,percent of total billed charges,,,95,,6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6,
albuterol 2.5 mg/3 mL (0.083%) INH Sol 3 mL [KHKS],6192055,CDM,250,RC,76204-0200-60,NDC,,,Outpatient,3,ML,3.99,,,,80,,3.19,percent of total billed charges,,,,85,3.39,percent of total billed charges,,,77.7,,3.1,percent of total billed charges,,,95,,3.79,percent of total billed charges,,,60,,2.4,percent of total billed charges,,2.4,3.79,
albuterol 2.5 mg/3 mL (0.083%) INH Sol 3 mL [KHKS],6192055,CDM,250,RC,76204-0200-60,NDC,,,Inpatient,3,ML,3.99,,,,80,,3.19,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.1,percent of total billed charges,,,95,,3.79,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.79,
fluorescein ophthalmic 1 mg Test [KHKS],6192056,CDM,250,RC,17238-0900-11,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
fluorescein ophthalmic 1 mg Test [KHKS],6192056,CDM,250,RC,17238-0900-11,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
bumetanide 1 mg Tab [KHKS],6192057,CDM,250,RC,68382-0526-01,NDC,,,Outpatient,1,EA,8.09,,,,80,,6.47,percent of total billed charges,,,,85,6.88,percent of total billed charges,,,77.7,,6.29,percent of total billed charges,,,95,,7.69,percent of total billed charges,,,60,,4.85,percent of total billed charges,,4.85,7.69,
bumetanide 1 mg Tab [KHKS],6192057,CDM,250,RC,68382-0526-01,NDC,,,Inpatient,1,EA,8.09,,,,80,,6.47,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.29,percent of total billed charges,,,95,,7.69,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.69,
terbutaline 2.5 mg Tab [KHKS],6192058,CDM,250,RC,62559-0721-01,NDC,,,Outpatient,1,EA,16.33,,,,80,,13.06,percent of total billed charges,,,,85,13.88,percent of total billed charges,,,77.7,,12.68,percent of total billed charges,,,95,,15.51,percent of total billed charges,,,60,,9.8,percent of total billed charges,,9.8,15.51,
terbutaline 2.5 mg Tab [KHKS],6192058,CDM,250,RC,62559-0721-01,NDC,,,Inpatient,1,EA,16.33,,,,80,,13.06,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.68,percent of total billed charges,,,95,,15.51,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.51,
pantoprazole 40 mg Oral EC Tab [KHKS],6192059,CDM,250,RC,63739-0564-10,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
pantoprazole 40 mg Oral EC Tab [KHKS],6192059,CDM,250,RC,63739-0564-10,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
levofloxacin 500 mg/100 mL D5W PREMIX IV Sol [KHKS],6192060,CDM,636,RC,J1956,HCPCS,00143-9721-01,NDC,Outpatient,100,ML,99.72,,,,80,,79.78,percent of total billed charges,,,,50,0.73,fee schedule,,,77.7,,77.48,percent of total billed charges,,,95,,94.73,percent of total billed charges,,,60,,59.83,percent of total billed charges,,0.73,94.73,
levofloxacin 500 mg/100 mL D5W PREMIX IV Sol [KHKS],6192060,CDM,636,RC,J1956,HCPCS,00143-9721-01,NDC,Inpatient,100,ML,99.72,,,,80,,79.78,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,77.48,percent of total billed charges,,,95,,94.73,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,94.73,
sodium bicarbonate 8.4% IV Sol 50 mL [KHKS],6192061,CDM,250,RC,76329-3352-01,NDC,,,Outpatient,50,ML,53.42,,,,80,,42.74,percent of total billed charges,,,,85,45.41,percent of total billed charges,,,77.7,,41.51,percent of total billed charges,,,95,,50.75,percent of total billed charges,,,60,,32.05,percent of total billed charges,,32.05,50.75,
sodium bicarbonate 8.4% IV Sol 50 mL [KHKS],6192061,CDM,250,RC,76329-3352-01,NDC,,,Inpatient,50,ML,53.42,,,,80,,42.74,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,41.51,percent of total billed charges,,,95,,50.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,50.75,
morphine 15 mg Tab [KHKS],6192062,CDM,250,RC,00054-0235-24,NDC,,,Outpatient,1,EA,2.73,,,,80,,2.18,percent of total billed charges,,,,85,2.32,percent of total billed charges,,,77.7,,2.12,percent of total billed charges,,,95,,2.59,percent of total billed charges,,,60,,1.64,percent of total billed charges,,1.64,2.59,
morphine 15 mg Tab [KHKS],6192062,CDM,250,RC,00054-0235-24,NDC,,,Inpatient,1,EA,2.73,,,,80,,2.18,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.12,percent of total billed charges,,,95,,2.59,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.59,
QUEtiapine 25 mg Tab [KHKS],6192063,CDM,250,RC,00904-6638-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
QUEtiapine 25 mg Tab [KHKS],6192063,CDM,250,RC,00904-6638-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
metoprolol tartrate 25 mg Tab [KHKS],6192064,CDM,250,RC,51079-0255-20,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
metoprolol tartrate 25 mg Tab [KHKS],6192064,CDM,250,RC,51079-0255-20,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
ketamine 10 mg/mL Inj Sol 20 mL [KHKS],6192065,CDM,250,RC,67457-0181-20,NDC,,,Outpatient,20,ML,72.39,,,,80,,57.91,percent of total billed charges,,,,85,61.53,percent of total billed charges,,,77.7,,56.24,percent of total billed charges,,,95,,68.77,percent of total billed charges,,,60,,43.43,percent of total billed charges,,43.43,68.77,
ketamine 10 mg/mL Inj Sol 20 mL [KHKS],6192065,CDM,250,RC,67457-0181-20,NDC,,,Inpatient,20,ML,72.39,,,,80,,57.91,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,56.24,percent of total billed charges,,,95,,68.77,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,68.77,
bupivacaine 0.25% PF Inj Sol 10 mL Vial [KHKS],6192066,CDM,636,RC,J0665,HCPCS,00409-1159-01,NDC,Outpatient,10,ML,5.99,,,,80,,4.79,percent of total billed charges,,,,85,5.09,percent of total billed charges,,,77.7,,4.66,percent of total billed charges,,,95,,5.69,percent of total billed charges,,,60,,3.6,percent of total billed charges,,3.6,5.69,
bupivacaine 0.25% PF Inj Sol 10 mL Vial [KHKS],6192066,CDM,636,RC,J0665,HCPCS,00409-1159-01,NDC,Inpatient,10,ML,5.99,,,,80,,4.79,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.66,percent of total billed charges,,,95,,5.69,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.69,
arformoterol 15 mcg/2 mL Inh Sol [KHKS],6192067,CDM,250,RC,63402-0911-30,NDC,,,Outpatient,2,ML,67.54,,,,80,,54.03,percent of total billed charges,,,,85,57.41,percent of total billed charges,,,77.7,,52.48,percent of total billed charges,,,95,,64.16,percent of total billed charges,,,60,,40.52,percent of total billed charges,,40.52,64.16,
arformoterol 15 mcg/2 mL Inh Sol [KHKS],6192067,CDM,250,RC,63402-0911-30,NDC,,,Inpatient,2,ML,67.54,,,,80,,54.03,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,52.48,percent of total billed charges,,,95,,64.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,64.16,
"nystatin 100,000 units/mL Oral Susp 60 mL [KHKS]",6192068,CDM,250,RC,00121-0868-02,NDC,,,Outpatient,60,ML,43.2,,,,80,,34.56,percent of total billed charges,,,,85,36.72,percent of total billed charges,,,77.7,,33.57,percent of total billed charges,,,95,,41.04,percent of total billed charges,,,60,,25.92,percent of total billed charges,,25.92,41.04,
"nystatin 100,000 units/mL Oral Susp 60 mL [KHKS]",6192068,CDM,250,RC,00121-0868-02,NDC,,,Inpatient,60,ML,43.2,,,,80,,34.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,33.57,percent of total billed charges,,,95,,41.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,41.04,
Multiple Vitamins Tab [KHKS],6192069,CDM,250,RC,00904-0530-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
Multiple Vitamins Tab [KHKS],6192069,CDM,250,RC,00904-0530-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
benzocaine Top 20% Spray 57 gm [KHKS],6192070,CDM,250,RC,63736-0378-82,NDC,,,Outpatient,57,EA,20.42,,,,80,,16.34,percent of total billed charges,,,,85,17.36,percent of total billed charges,,,77.7,,15.87,percent of total billed charges,,,95,,19.4,percent of total billed charges,,,60,,12.25,percent of total billed charges,,12.25,19.4,
benzocaine Top 20% Spray 57 gm [KHKS],6192070,CDM,250,RC,63736-0378-82,NDC,,,Inpatient,57,EA,20.42,,,,80,,16.34,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,15.87,percent of total billed charges,,,95,,19.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,19.4,
levalbuterol 0.63 mg/3 mL Inh Sol [KHKS],6192071,CDM,250,RC,16714-0095-25,NDC,,,Outpatient,3,ML,10.89,,,,80,,8.71,percent of total billed charges,,,,85,9.26,percent of total billed charges,,,77.7,,8.46,percent of total billed charges,,,95,,10.35,percent of total billed charges,,,60,,6.53,percent of total billed charges,,6.53,10.35,
levalbuterol 0.63 mg/3 mL Inh Sol [KHKS],6192071,CDM,250,RC,16714-0095-25,NDC,,,Inpatient,3,ML,10.89,,,,80,,8.71,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.46,percent of total billed charges,,,95,,10.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.35,
sevoflurane Inh Liq 250 mL [KHKS],6192073,CDM,250,RC,00074-4456-51,NDC,,,Outpatient,250,ML,519.44,,,,80,,415.55,percent of total billed charges,,,,85,441.52,percent of total billed charges,,,77.7,,403.61,percent of total billed charges,,,95,,493.47,percent of total billed charges,,,60,,311.67,percent of total billed charges,,311.67,493.47,
sevoflurane Inh Liq 250 mL [KHKS],6192073,CDM,250,RC,00074-4456-51,NDC,,,Inpatient,250,ML,519.44,,,,80,,415.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,403.61,percent of total billed charges,,,95,,493.47,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,493.47,
valsartan 80 mg Tab [KHKS],6192074,CDM,250,RC,31722-0152-90,NDC,,,Outpatient,1,EA,14.54,,,,80,,11.63,percent of total billed charges,,,,85,12.36,percent of total billed charges,,,77.7,,11.3,percent of total billed charges,,,95,,13.82,percent of total billed charges,,,60,,8.73,percent of total billed charges,,8.73,13.82,
valsartan 80 mg Tab [KHKS],6192074,CDM,250,RC,31722-0152-90,NDC,,,Inpatient,1,EA,14.54,,,,80,,11.63,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.3,percent of total billed charges,,,95,,13.82,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.82,
Prenatal Multivitamins with Folic Acid 1.25 mg oral Tab [KHKS],6192075,CDM,250,RC,13811-0027-10,NDC,,,Outpatient,1,EA,4.95,,,,80,,3.96,percent of total billed charges,,,,85,4.21,percent of total billed charges,,,77.7,,3.85,percent of total billed charges,,,95,,4.7,percent of total billed charges,,,60,,2.97,percent of total billed charges,,2.97,4.7,
Prenatal Multivitamins with Folic Acid 1.25 mg oral Tab [KHKS],6192075,CDM,250,RC,13811-0027-10,NDC,,,Inpatient,1,EA,4.95,,,,80,,3.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.85,percent of total billed charges,,,95,,4.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.7,
AlOH/diphenhyd/lidocaine/MgOH/simeth Top 3.15 g-0.2 g-1.6 g-3.15 g-0.315 g/237 mL Susp [KHKS],6192077,CDM,250,RC,65628-0050-04,NDC,,,Outpatient,119,ML,270,,,,80,,216,percent of total billed charges,,,,85,229.5,percent of total billed charges,,,77.7,,209.79,percent of total billed charges,,,95,,256.5,percent of total billed charges,,,60,,162,percent of total billed charges,,162,256.5,
AlOH/diphenhyd/lidocaine/MgOH/simeth Top 3.15 g-0.2 g-1.6 g-3.15 g-0.315 g/237 mL Susp [KHKS],6192077,CDM,250,RC,65628-0050-04,NDC,,,Inpatient,119,ML,270,,,,80,,216,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,209.79,percent of total billed charges,,,95,,256.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,256.5,
propranolol 10 mg Tab [KHKS],6192079,CDM,250,RC,00904-6550-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
propranolol 10 mg Tab [KHKS],6192079,CDM,250,RC,00904-6550-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
terbutaline 1 mg/mL Inj Sol 1 mL [KHKS],6192080,CDM,636,RC,J3105,HCPCS,63323-0665-01,NDC,Outpatient,1,ML,64.76,,,,80,,51.81,percent of total billed charges,,,,50,0.85,fee schedule,,,77.7,,50.32,percent of total billed charges,,,95,,61.53,percent of total billed charges,,,60,,38.86,percent of total billed charges,,0.85,61.53,
terbutaline 1 mg/mL Inj Sol 1 mL [KHKS],6192080,CDM,636,RC,J3105,HCPCS,63323-0665-01,NDC,Inpatient,1,ML,64.76,,,,80,,51.81,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,50.32,percent of total billed charges,,,95,,61.53,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,61.53,
albuterol CFC free 90 mcg/inh Inh Aer w/Adapt 8 gm[KHKS],6192081,CDM,250,RC,00173-0682-24,NDC,,,Outpatient,8,EA,81.78,,,,80,,65.42,percent of total billed charges,,,,85,69.51,percent of total billed charges,,,77.7,,63.54,percent of total billed charges,,,95,,77.69,percent of total billed charges,,,60,,49.07,percent of total billed charges,,49.07,77.69,
albuterol CFC free 90 mcg/inh Inh Aer w/Adapt 8 gm[KHKS],6192081,CDM,250,RC,00173-0682-24,NDC,,,Inpatient,8,EA,81.78,,,,80,,65.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,63.54,percent of total billed charges,,,95,,77.69,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.69,
acetaminophen-HYDROcodone 325 mg-7.5 mg Tab [KHKS],6192082,CDM,250,RC,00406-0124-62,NDC,,,Outpatient,1,EA,2.66,,,,80,,2.13,percent of total billed charges,,,,85,2.26,percent of total billed charges,,,77.7,,2.06,percent of total billed charges,,,95,,2.52,percent of total billed charges,,,60,,1.59,percent of total billed charges,,1.59,2.52,
acetaminophen-HYDROcodone 325 mg-7.5 mg Tab [KHKS],6192082,CDM,250,RC,00406-0124-62,NDC,,,Inpatient,1,EA,2.66,,,,80,,2.13,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.06,percent of total billed charges,,,95,,2.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.52,
cefTRIAXone 1 g Inj Add-Vantage Vial [KHKS],6192083,CDM,636,RC,J0696,HCPCS,00409-7333-49,NDC,Outpatient,1,EA,15.59,,,,80,,12.47,percent of total billed charges,,,,50,0.4,fee schedule,,,77.7,,12.11,percent of total billed charges,,,95,,14.81,percent of total billed charges,,,60,,9.35,percent of total billed charges,,0.4,14.81,
cefTRIAXone 1 g Inj Add-Vantage Vial [KHKS],6192083,CDM,636,RC,J0696,HCPCS,00409-7333-49,NDC,Inpatient,1,EA,15.59,,,,80,,12.47,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.11,percent of total billed charges,,,95,,14.81,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,14.81,
methylPREDNISolone 500 mg IV Inj Sol [KHKS],6192084,CDM,636,RC,J2919,HCPCS,00009-0758-01,NDC,Outpatient,1,EA,83.22,,,,80,,66.58,percent of total billed charges,,,,85,70.74,percent of total billed charges,,,77.7,,64.66,percent of total billed charges,,,95,,79.06,percent of total billed charges,,,60,,49.93,percent of total billed charges,,49.93,79.06,
methylPREDNISolone 500 mg IV Inj Sol [KHKS],6192084,CDM,636,RC,J2919,HCPCS,00009-0758-01,NDC,Inpatient,1,EA,83.22,,,,80,,66.58,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,64.66,percent of total billed charges,,,95,,79.06,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,79.06,
pregabalin 75 mg Oral Cap [KHKS],6192085,CDM,250,RC,60687-0495-01,NDC,,,Outpatient,1,EA,4.85,,,,80,,3.88,percent of total billed charges,,,,85,4.12,percent of total billed charges,,,77.7,,3.77,percent of total billed charges,,,95,,4.61,percent of total billed charges,,,60,,2.91,percent of total billed charges,,2.91,4.61,
pregabalin 75 mg Oral Cap [KHKS],6192085,CDM,250,RC,60687-0495-01,NDC,,,Inpatient,1,EA,4.85,,,,80,,3.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.77,percent of total billed charges,,,95,,4.61,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.61,
celecoxib 100 mg Cap [KHKS],6192086,CDM,250,RC,00904-6502-61,NDC,,,Outpatient,1,EA,13.1,,,,80,,10.48,percent of total billed charges,,,,85,11.14,percent of total billed charges,,,77.7,,10.18,percent of total billed charges,,,95,,12.44,percent of total billed charges,,,60,,7.86,percent of total billed charges,,7.86,12.44,
celecoxib 100 mg Cap [KHKS],6192086,CDM,250,RC,00904-6502-61,NDC,,,Inpatient,1,EA,13.1,,,,80,,10.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.18,percent of total billed charges,,,95,,12.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,12.44,
morphine 1 mg/mL PF Inj Sol 10 mL [KHKS],6192087,CDM,636,RC,J2274,HCPCS,00641-6019-10,NDC,Outpatient,10,ML,104.25,,,,80,,83.4,percent of total billed charges,,,,50,10.75,fee schedule,,,77.7,,81,percent of total billed charges,,,95,,99.04,percent of total billed charges,,,60,,62.55,percent of total billed charges,,10.75,99.04,
morphine 1 mg/mL PF Inj Sol 10 mL [KHKS],6192087,CDM,636,RC,J2274,HCPCS,00641-6019-10,NDC,Inpatient,10,ML,104.25,,,,80,,83.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,81,percent of total billed charges,,,95,,99.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,99.04,
ciprofloxacin 400 mg/200 mL IV PREMIX Sol [KHKS],6192088,CDM,636,RC,J0744,HCPCS,25021-0114-87,NDC,Outpatient,200,ML,25.16,,,,80,,20.13,percent of total billed charges,,,,50,0.82,fee schedule,,,77.7,,19.55,percent of total billed charges,,,95,,23.91,percent of total billed charges,,,60,,15.1,percent of total billed charges,,0.82,23.91,
ciprofloxacin 400 mg/200 mL IV PREMIX Sol [KHKS],6192088,CDM,636,RC,J0744,HCPCS,25021-0114-87,NDC,Inpatient,200,ML,25.16,,,,80,,20.13,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.55,percent of total billed charges,,,95,,23.91,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,23.91,
dexamethasone 4 mg/mL Inj Sol 1 mL [KHKS],6192089,CDM,636,RC,J1100,HCPCS,67457-0419-01,NDC,Outpatient,1,ML,2.79,,,,80,,2.24,percent of total billed charges,,,,50,0.08,fee schedule,,,77.7,,2.17,percent of total billed charges,,,95,,2.66,percent of total billed charges,,,60,,1.68,percent of total billed charges,,0.08,2.66,
dexamethasone 4 mg/mL Inj Sol 1 mL [KHKS],6192089,CDM,636,RC,J1100,HCPCS,67457-0419-01,NDC,Inpatient,1,ML,2.79,,,,80,,2.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.17,percent of total billed charges,,,95,,2.66,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.66,
selegiline 5 mg Cap [KHKS],6192090,CDM,250,RC,60505-0055-01,NDC,,,Outpatient,1,EA,6.91,,,,80,,5.52,percent of total billed charges,,,,85,5.87,percent of total billed charges,,,77.7,,5.37,percent of total billed charges,,,95,,6.56,percent of total billed charges,,,60,,4.14,percent of total billed charges,,4.14,6.56,
selegiline 5 mg Cap [KHKS],6192090,CDM,250,RC,60505-0055-01,NDC,,,Inpatient,1,EA,6.91,,,,80,,5.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.37,percent of total billed charges,,,95,,6.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.56,
dexamethasone 1 mg/mL Oral Conc 5 mL Syringe [KHKS],6192091,CDM,250,RC,00054-3176-44,NDC,,,Outpatient,5,ML,16.09,,,,80,,12.87,percent of total billed charges,,,,85,13.68,percent of total billed charges,,,77.7,,12.5,percent of total billed charges,,,95,,15.28,percent of total billed charges,,,60,,9.65,percent of total billed charges,,9.65,15.28,
dexamethasone 1 mg/mL Oral Conc 5 mL Syringe [KHKS],6192091,CDM,250,RC,00054-3176-44,NDC,,,Inpatient,5,ML,16.09,,,,80,,12.87,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.5,percent of total billed charges,,,95,,15.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.28,
measles/mumps/rubella virus vaccine SubQ Inj 0.5 mL [KHKS],6192092,CDM,636,RC,00006-4681-00,NDC,,,Outpatient,1,ML,241.63,,,,80,,193.3,percent of total billed charges,,,,85,205.39,percent of total billed charges,,,77.7,,187.74,percent of total billed charges,,,95,,229.54,percent of total billed charges,,,60,,144.98,percent of total billed charges,,144.98,229.54,
measles/mumps/rubella virus vaccine SubQ Inj 0.5 mL [KHKS],6192092,CDM,636,RC,00006-4681-00,NDC,,,Inpatient,1,ML,241.63,,,,80,,193.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,187.74,percent of total billed charges,,,95,,229.54,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,229.54,
ropivacaine 0.2% Inj Sol 100 mL [KHKS],6192093,CDM,636,RC,J2795,HCPCS,25021-0671-66,NDC,Outpatient,100,ML,89.3,,,,80,,71.44,percent of total billed charges,,,,50,0.06,fee schedule,,,77.7,,69.39,percent of total billed charges,,,95,,84.84,percent of total billed charges,,,60,,53.58,percent of total billed charges,,0.06,84.84,
ropivacaine 0.2% Inj Sol 100 mL [KHKS],6192093,CDM,636,RC,J2795,HCPCS,25021-0671-66,NDC,Inpatient,100,ML,89.3,,,,80,,71.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,69.39,percent of total billed charges,,,95,,84.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,84.84,
diazepam 5 mg/mL Inj Sol 2 mL [KHKS],6192094,CDM,636,RC,J3360,HCPCS,00409-1273-32,NDC,Outpatient,2,ML,100.15,,,,80,,80.12,percent of total billed charges,,,,50,5.5,fee schedule,,,77.7,,77.82,percent of total billed charges,,,95,,95.14,percent of total billed charges,,,60,,60.09,percent of total billed charges,,5.5,95.14,
diazepam 5 mg/mL Inj Sol 2 mL [KHKS],6192094,CDM,636,RC,J3360,HCPCS,00409-1273-32,NDC,Inpatient,2,ML,100.15,,,,80,,80.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,77.82,percent of total billed charges,,,95,,95.14,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,95.14,
iohexol 350 mg/mL Inj Sol 50 mL [KHKS],6192095,CDM,636,RC,Q9967,HCPCS,00407-1414-89,NDC,Outpatient,50,ML,250,,,,80,,200,percent of total billed charges,,,,50,2.53,fee schedule,,,77.7,,194.25,percent of total billed charges,,,95,,237.5,percent of total billed charges,,,60,,150,percent of total billed charges,,2.53,237.5,
iohexol 350 mg/mL Inj Sol 50 mL [KHKS],6192095,CDM,636,RC,Q9967,HCPCS,00407-1414-89,NDC,Inpatient,50,ML,250,,,,80,,200,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,194.25,percent of total billed charges,,,95,,237.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,237.5,
PARoxetine 20 mg Tab [KHKS],6192096,CDM,250,RC,63739-0963-10,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
PARoxetine 20 mg Tab [KHKS],6192096,CDM,250,RC,63739-0963-10,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
Sodium Chloride 0.9% IV Sol 50 mL [KHKS],6192097,CDM,250,RC,J7040,HCPCS,00990-7984-36,NDC,Outpatient,50,ML,5.22,,,,80,,4.18,percent of total billed charges,,,,50,0.83,fee schedule,,,77.7,,4.06,percent of total billed charges,,,95,,4.96,percent of total billed charges,,,60,,3.13,percent of total billed charges,,0.83,4.96,
Sodium Chloride 0.9% IV Sol 50 mL [KHKS],6192097,CDM,250,RC,J7040,HCPCS,00990-7984-36,NDC,Inpatient,50,ML,5.22,,,,80,,4.18,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.06,percent of total billed charges,,,95,,4.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.96,
magnesium sulfate 50% Inj Sol 2 mL [KHKS],6192098,CDM,636,RC,J3475,HCPCS,63323-0064-23,NDC,Outpatient,2,ML,4.32,,,,80,,3.46,percent of total billed charges,,,,50,0.51,fee schedule,,,77.7,,3.36,percent of total billed charges,,,95,,4.1,percent of total billed charges,,,60,,2.59,percent of total billed charges,,0.51,4.1,
magnesium sulfate 50% Inj Sol 2 mL [KHKS],6192098,CDM,636,RC,J3475,HCPCS,63323-0064-23,NDC,Inpatient,2,ML,4.32,,,,80,,3.46,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.36,percent of total billed charges,,,95,,4.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.1,
Dextrose 5% in Water IV Sol 250 mL [KHKS],6192099,CDM,636,RC,J7060,HCPCS,00990-7922-02,NDC,Outpatient,250,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,50,1.12,fee schedule,,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,60,,11.34,percent of total billed charges,,1.12,17.96,
Dextrose 5% in Water IV Sol 250 mL [KHKS],6192099,CDM,636,RC,J7060,HCPCS,00990-7922-02,NDC,Inpatient,250,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.96,
simethicone 80 mg Chew Tab [KHKS],6192101,CDM,250,RC,00904-7206-60,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
simethicone 80 mg Chew Tab [KHKS],6192101,CDM,250,RC,00904-7206-60,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
tenecteplase 50. mg Powder-Inj,6192102,CDM,636,RC,J3101,HCPCS,50242-0120-47,NDC,Outpatient,1,EA,15380.03,,,,80,,12304.02,percent of total billed charges,,,,50,92.39,fee schedule,,,77.7,,11950.28,percent of total billed charges,,,95,,14611.03,percent of total billed charges,,,60,,9228.02,percent of total billed charges,,92.39,14611.03,
tenecteplase 50. mg Powder-Inj,6192102,CDM,636,RC,J3101,HCPCS,50242-0120-47,NDC,Inpatient,1,EA,15380.03,,,,80,,12304.02,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11950.28,percent of total billed charges,,,95,,14611.03,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,14611.03,
cefdinir 125 mg/5 mL Oral Susp 60 mL [KHKS],6192103,CDM,250,RC,65862-0218-60,NDC,,,Outpatient,60,ML,152.85,,,,80,,122.28,percent of total billed charges,,,,85,129.92,percent of total billed charges,,,77.7,,118.76,percent of total billed charges,,,95,,145.21,percent of total billed charges,,,60,,91.71,percent of total billed charges,,91.71,145.21,
cefdinir 125 mg/5 mL Oral Susp 60 mL [KHKS],6192103,CDM,250,RC,65862-0218-60,NDC,,,Inpatient,60,ML,152.85,,,,80,,122.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,118.76,percent of total billed charges,,,95,,145.21,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,145.21,
propofol 10 mg/mL IV Emulsion 20 mL [KHKS],6192104,CDM,636,RC,J2704,HCPCS,00069-0209-10,NDC,Outpatient,20,ML,15.56,,,,80,,12.45,percent of total billed charges,,,,50,0.09,fee schedule,,,77.7,,12.09,percent of total billed charges,,,95,,14.78,percent of total billed charges,,,60,,9.34,percent of total billed charges,,0.09,14.78,
propofol 10 mg/mL IV Emulsion 20 mL [KHKS],6192104,CDM,636,RC,J2704,HCPCS,00069-0209-10,NDC,Inpatient,20,ML,15.56,,,,80,,12.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.09,percent of total billed charges,,,95,,14.78,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,14.78,
fluconazole 150 mg Tab [KHKS],6192105,CDM,250,RC,16714-0692-11,NDC,,,Outpatient,1,EA,40.78,,,,80,,32.62,percent of total billed charges,,,,85,34.66,percent of total billed charges,,,77.7,,31.68,percent of total billed charges,,,95,,38.74,percent of total billed charges,,,60,,24.47,percent of total billed charges,,24.47,38.74,
fluconazole 150 mg Tab [KHKS],6192105,CDM,250,RC,16714-0692-11,NDC,,,Inpatient,1,EA,40.78,,,,80,,32.62,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,31.68,percent of total billed charges,,,95,,38.74,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,38.74,
ocular lubricant preserved Sol (Dry Eye Relief) 15mL [KHKS],6192106,CDM,250,RC,49348-0095-29,NDC,,,Outpatient,15,EA,14.37,,,,80,,11.5,percent of total billed charges,,,,85,12.21,percent of total billed charges,,,77.7,,11.17,percent of total billed charges,,,95,,13.65,percent of total billed charges,,,60,,8.62,percent of total billed charges,,8.62,13.65,
ocular lubricant preserved Sol (Dry Eye Relief) 15mL [KHKS],6192106,CDM,250,RC,49348-0095-29,NDC,,,Inpatient,15,EA,14.37,,,,80,,11.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.17,percent of total billed charges,,,95,,13.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.65,
bupivacaine 0.5% PF Inj Sol 30 mL [KHKS],6192107,CDM,636,RC,00409-1162-10,NDC,,,Outpatient,30,ML,6.65,,,,80,,5.32,percent of total billed charges,,,,85,5.65,percent of total billed charges,,,77.7,,5.17,percent of total billed charges,,,95,,6.32,percent of total billed charges,,,60,,3.99,percent of total billed charges,,3.99,6.32,
bupivacaine 0.5% PF Inj Sol 30 mL [KHKS],6192107,CDM,636,RC,00409-1162-10,NDC,,,Inpatient,30,ML,6.65,,,,80,,5.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.17,percent of total billed charges,,,95,,6.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.32,
sulfamethoxazole-trimethoprim 800 mg-160 mg Tab [KHKS],6192108,CDM,250,RC,00904-2725-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
sulfamethoxazole-trimethoprim 800 mg-160 mg Tab [KHKS],6192108,CDM,250,RC,00904-2725-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
lidocaine 2% 20 mg/mL PF IV Sol 5 mL Vial [KHKS],6192109,CDM,636,RC,J2003,HCPCS,63323-0208-05,NDC,Outpatient,5,ML,10.76,,,,80,,8.61,percent of total billed charges,,,,85,9.15,percent of total billed charges,,,77.7,,8.36,percent of total billed charges,,,95,,10.23,percent of total billed charges,,,60,,6.46,percent of total billed charges,,6.46,10.23,
lidocaine 2% 20 mg/mL PF IV Sol 5 mL Vial [KHKS],6192109,CDM,636,RC,J2003,HCPCS,63323-0208-05,NDC,Inpatient,5,ML,10.76,,,,80,,8.61,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.36,percent of total billed charges,,,95,,10.23,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.23,
dicyclomine 10 mg Cap [KHKS],6192110,CDM,250,RC,00527-0586-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
dicyclomine 10 mg Cap [KHKS],6192110,CDM,250,RC,00527-0586-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
promethazine 25 mg/mL Inj Sol 1 mL [KHKS],6192111,CDM,636,RC,J2550,HCPCS,00641-0948-35,NDC,Outpatient,1,ML,6.28,,,,80,,5.03,percent of total billed charges,,,,50,2.07,fee schedule,,,77.7,,4.88,percent of total billed charges,,,95,,5.97,percent of total billed charges,,,60,,3.77,percent of total billed charges,,2.07,5.97,
promethazine 25 mg/mL Inj Sol 1 mL [KHKS],6192111,CDM,636,RC,J2550,HCPCS,00641-0948-35,NDC,Inpatient,1,ML,6.28,,,,80,,5.03,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.88,percent of total billed charges,,,95,,5.97,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.97,
warfarin 1 mg Tab [KHKS],6192112,CDM,250,RC,00093-1712-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
warfarin 1 mg Tab [KHKS],6192112,CDM,250,RC,00093-1712-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
risperiDONE 0.25 mg Tab [KHKS],6192113,CDM,250,RC,00904-6357-61,NDC,,,Outpatient,1,EA,10.74,,,,80,,8.6,percent of total billed charges,,,,85,9.13,percent of total billed charges,,,77.7,,8.35,percent of total billed charges,,,95,,10.21,percent of total billed charges,,,60,,6.45,percent of total billed charges,,6.45,10.21,
risperiDONE 0.25 mg Tab [KHKS],6192113,CDM,250,RC,00904-6357-61,NDC,,,Inpatient,1,EA,10.74,,,,80,,8.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.35,percent of total billed charges,,,95,,10.21,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.21,
Dextrose 5% with 0.45% NaCl and KCl 20 mEq IV PREMIX Sol 1000 mL [KHKS],6192114,CDM,636,RC,J3480,HCPCS,00990-7902-09,NDC,Outpatient,1000,ML,25.45,,,,80,,20.36,percent of total billed charges,,,,50,0.09,fee schedule,,,77.7,,19.78,percent of total billed charges,,,95,,24.18,percent of total billed charges,,,60,,15.27,percent of total billed charges,,0.09,24.18,
Dextrose 5% with 0.45% NaCl and KCl 20 mEq IV PREMIX Sol 1000 mL [KHKS],6192114,CDM,636,RC,J3480,HCPCS,00990-7902-09,NDC,Inpatient,1000,ML,25.45,,,,80,,20.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.78,percent of total billed charges,,,95,,24.18,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,24.18,
amiodarone 50 mg/mL IV Sol 3 mL [KHKS],6192115,CDM,636,RC,J0282,HCPCS,63323-0616-03,NDC,Outpatient,3,ML,5.07,,,,80,,4.06,percent of total billed charges,,,,50,0.29,fee schedule,,,77.7,,3.94,percent of total billed charges,,,95,,4.82,percent of total billed charges,,,60,,3.04,percent of total billed charges,,0.29,4.82,
amiodarone 50 mg/mL IV Sol 3 mL [KHKS],6192115,CDM,636,RC,J0282,HCPCS,63323-0616-03,NDC,Inpatient,3,ML,5.07,,,,80,,4.06,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.94,percent of total billed charges,,,95,,4.82,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.82,
metoprolol succinate 50 mg ER Tab [KHKS],6192116,CDM,250,RC,00904-6323-61,NDC,,,Outpatient,1,EA,3.72,,,,80,,2.97,percent of total billed charges,,,,85,3.16,percent of total billed charges,,,77.7,,2.89,percent of total billed charges,,,95,,3.53,percent of total billed charges,,,60,,2.23,percent of total billed charges,,2.23,3.53,
metoprolol succinate 50 mg ER Tab [KHKS],6192116,CDM,250,RC,00904-6323-61,NDC,,,Inpatient,1,EA,3.72,,,,80,,2.97,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.89,percent of total billed charges,,,95,,3.53,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.53,
predniSONE 2.5 mg Tab [KHKS],6192117,CDM,250,RC,00054-8740-25,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
predniSONE 2.5 mg Tab [KHKS],6192117,CDM,250,RC,00054-8740-25,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
ceFAZolin 1 g Inj [KHKS],6192118,CDM,636,RC,J0690,HCPCS,00781-3451-96,NDC,Outpatient,1,EA,22.5,,,,80,,18,percent of total billed charges,,,,50,0.55,fee schedule,,,77.7,,17.48,percent of total billed charges,,,95,,21.38,percent of total billed charges,,,60,,13.5,percent of total billed charges,,0.55,21.38,
ceFAZolin 1 g Inj [KHKS],6192118,CDM,636,RC,J0690,HCPCS,00781-3451-96,NDC,Inpatient,1,EA,22.5,,,,80,,18,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,17.48,percent of total billed charges,,,95,,21.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,21.38,
Multiple Vitamins IV Sol 5 mL [KHKS],6192119,CDM,250,RC,54643-5649-01,NDC,,,Outpatient,5,ML,297.68,,,,80,,238.14,percent of total billed charges,,,,85,253.03,percent of total billed charges,,,77.7,,231.29,percent of total billed charges,,,95,,282.79,percent of total billed charges,,,60,,178.61,percent of total billed charges,,178.61,282.79,
Multiple Vitamins IV Sol 5 mL [KHKS],6192119,CDM,250,RC,54643-5649-01,NDC,,,Inpatient,5,ML,297.68,,,,80,,238.14,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,231.29,percent of total billed charges,,,95,,282.79,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,282.79,
ampicillin 1 g Inj [KHKS],6192120,CDM,636,RC,J0290,HCPCS,00409-3726-01,NDC,Outpatient,1,EA,12.79,,,,80,,10.23,percent of total billed charges,,,,50,0.65,fee schedule,,,77.7,,9.94,percent of total billed charges,,,95,,12.15,percent of total billed charges,,,60,,7.68,percent of total billed charges,,0.65,12.15,
ampicillin 1 g Inj [KHKS],6192120,CDM,636,RC,J0290,HCPCS,00409-3726-01,NDC,Inpatient,1,EA,12.79,,,,80,,10.23,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.94,percent of total billed charges,,,95,,12.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,12.15,
nalbuphine 10 mg/mL Inj Sol 1 mL [KHKS],6192121,CDM,636,RC,J2300,HCPCS,00409-1463-01,NDC,Outpatient,1,ML,13.23,,,,80,,10.59,percent of total billed charges,,,,50,1.79,fee schedule,,,77.7,,10.28,percent of total billed charges,,,95,,12.57,percent of total billed charges,,,60,,7.94,percent of total billed charges,,1.79,12.57,
nalbuphine 10 mg/mL Inj Sol 1 mL [KHKS],6192121,CDM,636,RC,J2300,HCPCS,00409-1463-01,NDC,Inpatient,1,ML,13.23,,,,80,,10.59,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.28,percent of total billed charges,,,95,,12.57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,12.57,
"EPINEPHrine-lidocaine 1:200,000-2% PF Inj Sol 10 mL Vial [KHKS]",6192122,CDM,636,RC,J2004,HCPCS,63323-0489-17,NDC,Outpatient,10,ML,32.15,,,,80,,25.72,percent of total billed charges,,,,85,27.33,percent of total billed charges,,,77.7,,24.98,percent of total billed charges,,,95,,30.54,percent of total billed charges,,,60,,19.29,percent of total billed charges,,19.29,30.54,
"EPINEPHrine-lidocaine 1:200,000-2% PF Inj Sol 10 mL Vial [KHKS]",6192122,CDM,636,RC,J2004,HCPCS,63323-0489-17,NDC,Inpatient,10,ML,32.15,,,,80,,25.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,24.98,percent of total billed charges,,,95,,30.54,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,30.54,
diazepam 5 mg Tab [KHKS],6192123,CDM,250,RC,51079-0285-20,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
diazepam 5 mg Tab [KHKS],6192123,CDM,250,RC,51079-0285-20,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
glucose 40% Oral gel 37.5 gm [KHKS],6192124,CDM,250,RC,00574-0069-15,NDC,,,Outpatient,37.5,EA,11.85,,,,80,,9.48,percent of total billed charges,,,,85,10.07,percent of total billed charges,,,77.7,,9.21,percent of total billed charges,,,95,,11.26,percent of total billed charges,,,60,,7.11,percent of total billed charges,,7.11,11.26,
glucose 40% Oral gel 37.5 gm [KHKS],6192124,CDM,250,RC,00574-0069-15,NDC,,,Inpatient,37.5,EA,11.85,,,,80,,9.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.21,percent of total billed charges,,,95,,11.26,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.26,
carbidopa-levodopa 10 mg-100 mg Tab [KHKS],6192125,CDM,250,RC,00228-2538-10,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
carbidopa-levodopa 10 mg-100 mg Tab [KHKS],6192125,CDM,250,RC,00228-2538-10,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
ibuprofen 800 mg Tab [KHKS],6192126,CDM,250,RC,00904-5855-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
ibuprofen 800 mg Tab [KHKS],6192126,CDM,250,RC,00904-5855-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
chloroprocaine 3% PF Inj Sol 20 mL [KHKS],6192127,CDM,636,RC,J2401,HCPCS,63323-0478-27,NDC,Outpatient,20,ML,80.57,,,,80,,64.45,percent of total billed charges,,,,50,0.03,fee schedule,,,77.7,,62.6,percent of total billed charges,,,95,,76.54,percent of total billed charges,,,60,,48.34,percent of total billed charges,,0.03,76.54,
chloroprocaine 3% PF Inj Sol 20 mL [KHKS],6192127,CDM,636,RC,J2401,HCPCS,63323-0478-27,NDC,Inpatient,20,ML,80.57,,,,80,,64.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,62.6,percent of total billed charges,,,95,,76.54,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,76.54,
ketorolac 30 mg/mL Inj Sol 1 mL [KHKS],6192129,CDM,636,RC,J1885,HCPCS,72611-0722-25,NDC,Outpatient,1,ML,4.03,,,,80,,3.23,percent of total billed charges,,,,50,0.38,fee schedule,,,77.7,,3.13,percent of total billed charges,,,95,,3.83,percent of total billed charges,,,60,,2.42,percent of total billed charges,,0.38,3.83,
ketorolac 30 mg/mL Inj Sol 1 mL [KHKS],6192129,CDM,636,RC,J1885,HCPCS,72611-0722-25,NDC,Inpatient,1,ML,4.03,,,,80,,3.23,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.13,percent of total billed charges,,,95,,3.83,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.83,
vancomycin 1 g IV Inj Sol [KHKS],6192130,CDM,636,RC,J3371,HCPCS,67457-0340-01,NDC,Outpatient,1,EA,57.74,,,,80,,46.2,percent of total billed charges,,,,50,4.83,fee schedule,,,77.7,,44.87,percent of total billed charges,,,95,,54.86,percent of total billed charges,,,60,,34.65,percent of total billed charges,,4.83,54.86,
vancomycin 1 g IV Inj Sol [KHKS],6192130,CDM,636,RC,J3371,HCPCS,67457-0340-01,NDC,Inpatient,1,EA,57.74,,,,80,,46.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,44.87,percent of total billed charges,,,95,,54.86,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,54.86,
potassium chloride 2 mEq/mL IV Sol [KHKS],6192131,CDM,636,RC,J3480,HCPCS,00409-6635-01,NDC,Outpatient,5,ML,15.47,,,,80,,12.38,percent of total billed charges,,,,50,0.09,fee schedule,,,77.7,,12.02,percent of total billed charges,,,95,,14.7,percent of total billed charges,,,60,,9.28,percent of total billed charges,,0.09,14.7,
potassium chloride 2 mEq/mL IV Sol [KHKS],6192131,CDM,636,RC,J3480,HCPCS,00409-6635-01,NDC,Inpatient,5,ML,15.47,,,,80,,12.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.02,percent of total billed charges,,,95,,14.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,14.7,
midazolam 5 mg/mL PF Inj Sol 1 mL [KHKS],6192132,CDM,636,RC,J2250,HCPCS,00409-2308-49,NDC,Outpatient,1,ML,3.76,,,,80,,3.01,percent of total billed charges,,,,50,0.11,fee schedule,,,77.7,,2.92,percent of total billed charges,,,95,,3.57,percent of total billed charges,,,60,,2.26,percent of total billed charges,,0.11,3.57,
midazolam 5 mg/mL PF Inj Sol 1 mL [KHKS],6192132,CDM,636,RC,J2250,HCPCS,00409-2308-49,NDC,Inpatient,1,ML,3.76,,,,80,,3.01,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.92,percent of total billed charges,,,95,,3.57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.57,
lidocaine 2% PF Inj Sol 10 mL Ampule [KHKS],6192133,CDM,636,RC,J2003,HCPCS,00409-4282-02,NDC,Outpatient,10,ML,13.92,,,,80,,11.14,percent of total billed charges,,,,85,11.83,percent of total billed charges,,,77.7,,10.82,percent of total billed charges,,,95,,13.23,percent of total billed charges,,,60,,8.35,percent of total billed charges,,8.35,13.23,
lidocaine 2% PF Inj Sol 10 mL Ampule [KHKS],6192133,CDM,636,RC,J2003,HCPCS,00409-4282-02,NDC,Inpatient,10,ML,13.92,,,,80,,11.14,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.82,percent of total billed charges,,,95,,13.23,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.23,
diltiazem 30 mg Tab [KHKS],6192134,CDM,250,RC,00093-0318-01,NDC,,,Outpatient,1,EA,3,,,,80,,2.4,percent of total billed charges,,,,85,2.55,percent of total billed charges,,,77.7,,2.33,percent of total billed charges,,,95,,2.85,percent of total billed charges,,,60,,1.8,percent of total billed charges,,1.8,2.85,
diltiazem 30 mg Tab [KHKS],6192134,CDM,250,RC,00093-0318-01,NDC,,,Inpatient,1,EA,3,,,,80,,2.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.33,percent of total billed charges,,,95,,2.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.85,
meloxicam 7.5 mg Tab [KHKS],6192136,CDM,250,RC,68382-0050-01,NDC,,,Outpatient,1,EA,9.51,,,,80,,7.6,percent of total billed charges,,,,85,8.08,percent of total billed charges,,,77.7,,7.39,percent of total billed charges,,,95,,9.03,percent of total billed charges,,,60,,5.7,percent of total billed charges,,5.7,9.03,
meloxicam 7.5 mg Tab [KHKS],6192136,CDM,250,RC,68382-0050-01,NDC,,,Inpatient,1,EA,9.51,,,,80,,7.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.39,percent of total billed charges,,,95,,9.03,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.03,
donepezil 5 mg Tab [KHKS],6192137,CDM,250,RC,60687-0292-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
donepezil 5 mg Tab [KHKS],6192137,CDM,250,RC,60687-0292-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
silver nitrate Topical - Stick [KHKS],6192138,CDM,250,RC,12870-0001-02,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
silver nitrate Topical - Stick [KHKS],6192138,CDM,250,RC,12870-0001-02,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
digoxin 250 mcg/mL (0.25 mg/mL) Inj Sol 2 mL [KHKS],6192139,CDM,636,RC,J1160,HCPCS,00641-1410-35,NDC,Outpatient,2,ML,19.8,,,,80,,15.84,percent of total billed charges,,,,50,5.23,fee schedule,,,77.7,,15.38,percent of total billed charges,,,95,,18.81,percent of total billed charges,,,60,,11.88,percent of total billed charges,,5.23,18.81,
digoxin 250 mcg/mL (0.25 mg/mL) Inj Sol 2 mL [KHKS],6192139,CDM,636,RC,J1160,HCPCS,00641-1410-35,NDC,Inpatient,2,ML,19.8,,,,80,,15.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,15.38,percent of total billed charges,,,95,,18.81,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,18.81,
phytonadione 5 mg Tab [KHKS],6192140,CDM,250,RC,69238-1051-03,NDC,,,Outpatient,1,EA,200.96,,,,80,,160.77,percent of total billed charges,,,,85,170.82,percent of total billed charges,,,77.7,,156.15,percent of total billed charges,,,95,,190.91,percent of total billed charges,,,60,,120.58,percent of total billed charges,,120.58,190.91,
phytonadione 5 mg Tab [KHKS],6192140,CDM,250,RC,69238-1051-03,NDC,,,Inpatient,1,EA,200.96,,,,80,,160.77,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,156.15,percent of total billed charges,,,95,,190.91,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,190.91,
prochlorperazine 5 mg/mL Inj Sol 2 mL [KHKS],6192141,CDM,636,RC,J0780,HCPCS,70860-0778-02,NDC,Outpatient,2,ML,22.86,,,,80,,18.29,percent of total billed charges,,,,50,1.9,fee schedule,,,77.7,,17.76,percent of total billed charges,,,95,,21.72,percent of total billed charges,,,60,,13.72,percent of total billed charges,,1.9,21.72,
prochlorperazine 5 mg/mL Inj Sol 2 mL [KHKS],6192141,CDM,636,RC,J0780,HCPCS,70860-0778-02,NDC,Inpatient,2,ML,22.86,,,,80,,18.29,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,17.76,percent of total billed charges,,,95,,21.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,21.72,
ampicillin 1 g ADDV-Inj [KHKS],6192142,CDM,636,RC,J0290,HCPCS,00781-9412-92,NDC,Outpatient,1,EA,25.92,,,,80,,20.74,percent of total billed charges,,,,50,0.65,fee schedule,,,77.7,,20.14,percent of total billed charges,,,95,,24.62,percent of total billed charges,,,60,,15.55,percent of total billed charges,,0.65,24.62,
ampicillin 1 g ADDV-Inj [KHKS],6192142,CDM,636,RC,J0290,HCPCS,00781-9412-92,NDC,Inpatient,1,EA,25.92,,,,80,,20.74,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,20.14,percent of total billed charges,,,95,,24.62,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,24.62,
topiramate 25 mg Tab [KHKS],6192143,CDM,250,RC,68084-0342-01,NDC,,,Outpatient,1,EA,6.3,,,,80,,5.04,percent of total billed charges,,,,85,5.36,percent of total billed charges,,,77.7,,4.9,percent of total billed charges,,,95,,5.99,percent of total billed charges,,,60,,3.78,percent of total billed charges,,3.78,5.99,
topiramate 25 mg Tab [KHKS],6192143,CDM,250,RC,68084-0342-01,NDC,,,Inpatient,1,EA,6.3,,,,80,,5.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.9,percent of total billed charges,,,95,,5.99,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.99,
potassium chloride 10 mEq/50 mL IV PREMIX Sol [KHKS],6192144,CDM,636,RC,J3480,HCPCS,00990-7075-14,NDC,Outpatient,50,ML,18.04,,,,80,,14.43,percent of total billed charges,,,,50,0.09,fee schedule,,,77.7,,14.01,percent of total billed charges,,,95,,17.13,percent of total billed charges,,,60,,10.82,percent of total billed charges,,0.09,17.13,
potassium chloride 10 mEq/50 mL IV PREMIX Sol [KHKS],6192144,CDM,636,RC,J3480,HCPCS,00990-7075-14,NDC,Inpatient,50,ML,18.04,,,,80,,14.43,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.01,percent of total billed charges,,,95,,17.13,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.13,
midodrine 10 mg Tab [KHKS],6192145,CDM,250,RC,00245-0213-11,NDC,,,Outpatient,1,EA,29.16,,,,80,,23.33,percent of total billed charges,,,,85,24.79,percent of total billed charges,,,77.7,,22.66,percent of total billed charges,,,95,,27.7,percent of total billed charges,,,60,,17.5,percent of total billed charges,,17.5,27.7,
midodrine 10 mg Tab [KHKS],6192145,CDM,250,RC,00245-0213-11,NDC,,,Inpatient,1,EA,29.16,,,,80,,23.33,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,22.66,percent of total billed charges,,,95,,27.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,27.7,
Dextrose 10% in Water IV Sol 250 mL [KHKS],6192147,CDM,250,RC,00990-7930-02,NDC,,,Outpatient,250,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,85,16.07,percent of total billed charges,,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,60,,11.34,percent of total billed charges,,11.34,17.96,
Dextrose 10% in Water IV Sol 250 mL [KHKS],6192147,CDM,250,RC,00990-7930-02,NDC,,,Inpatient,250,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.96,
fentaNYL 50 mcg/mL Inj Sol 2mL [KHKS],6192148,CDM,636,RC,J3010,HCPCS,00641-6027-25,NDC,Outpatient,2,ML,7.85,,,,80,,6.28,percent of total billed charges,,,,50,0.59,fee schedule,,,77.7,,6.1,percent of total billed charges,,,95,,7.46,percent of total billed charges,,,60,,4.71,percent of total billed charges,,0.59,7.46,
fentaNYL 50 mcg/mL Inj Sol 2mL [KHKS],6192148,CDM,636,RC,J3010,HCPCS,00641-6027-25,NDC,Inpatient,2,ML,7.85,,,,80,,6.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.1,percent of total billed charges,,,95,,7.46,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.46,
glimepiride 2 mg Tab [KHKS],6192151,CDM,250,RC,16729-0002-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
glimepiride 2 mg Tab [KHKS],6192151,CDM,250,RC,16729-0002-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
ofloxacin Otic 0.3% Sol 5 mL [KHKS],6192153,CDM,250,RC,69238-1615-03,NDC,,,Outpatient,5,EA,354.02,,,,80,,283.21,percent of total billed charges,,,,85,300.92,percent of total billed charges,,,77.7,,275.07,percent of total billed charges,,,95,,336.31,percent of total billed charges,,,60,,212.41,percent of total billed charges,,212.41,336.31,
ofloxacin Otic 0.3% Sol 5 mL [KHKS],6192153,CDM,250,RC,69238-1615-03,NDC,,,Inpatient,5,EA,354.02,,,,80,,283.21,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,275.07,percent of total billed charges,,,95,,336.31,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,336.31,
hydrOXYzine hydrochloride 25 mg Tab [KHKS],6192154,CDM,250,RC,63739-0486-10,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
hydrOXYzine hydrochloride 25 mg Tab [KHKS],6192154,CDM,250,RC,63739-0486-10,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
metroNIDAZOLE 500 mg/100 mL IV Sol [KHKS],6192155,CDM,636,RC,J1836,HCPCS,00409-7811-24,NDC,Outpatient,100,ML,6.91,,,,80,,5.53,percent of total billed charges,,,,85,5.87,percent of total billed charges,,,77.7,,5.37,percent of total billed charges,,,95,,6.56,percent of total billed charges,,,60,,4.15,percent of total billed charges,,4.15,6.56,
metroNIDAZOLE 500 mg/100 mL IV Sol [KHKS],6192155,CDM,636,RC,J1836,HCPCS,00409-7811-24,NDC,Inpatient,100,ML,6.91,,,,80,,5.53,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.37,percent of total billed charges,,,95,,6.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.56,
flumazenil 0.1 mg/mL IV Sol [KHKS],6192156,CDM,250,RC,00641-6031-10,NDC,,,Outpatient,5,ML,36.9,,,,80,,29.52,percent of total billed charges,,,,85,31.37,percent of total billed charges,,,77.7,,28.67,percent of total billed charges,,,95,,35.06,percent of total billed charges,,,60,,22.14,percent of total billed charges,,22.14,35.06,
flumazenil 0.1 mg/mL IV Sol [KHKS],6192156,CDM,250,RC,00641-6031-10,NDC,,,Inpatient,5,ML,36.9,,,,80,,29.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,28.67,percent of total billed charges,,,95,,35.06,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,35.06,
tetracaine OPHTH 0.5% Sol 4 mL [KHKS],6192157,CDM,250,RC,00065-0741-14,NDC,,,Outpatient,4,EA,34.95,,,,80,,27.96,percent of total billed charges,,,,85,29.71,percent of total billed charges,,,77.7,,27.16,percent of total billed charges,,,95,,33.2,percent of total billed charges,,,60,,20.97,percent of total billed charges,,20.97,33.2,
tetracaine OPHTH 0.5% Sol 4 mL [KHKS],6192157,CDM,250,RC,00065-0741-14,NDC,,,Inpatient,4,EA,34.95,,,,80,,27.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,27.16,percent of total billed charges,,,95,,33.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,33.2,
lidocaine 2% (20 mg/mL) PF Inj Sol 2 mL [KHKS],6192158,CDM,636,RC,J2003,HCPCS,63323-0495-27,NDC,Outpatient,2,ML,9.18,,,,80,,7.34,percent of total billed charges,,,,85,7.8,percent of total billed charges,,,77.7,,7.13,percent of total billed charges,,,95,,8.72,percent of total billed charges,,,60,,5.51,percent of total billed charges,,5.51,8.72,
lidocaine 2% (20 mg/mL) PF Inj Sol 2 mL [KHKS],6192158,CDM,636,RC,J2003,HCPCS,63323-0495-27,NDC,Inpatient,2,ML,9.18,,,,80,,7.34,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.13,percent of total billed charges,,,95,,8.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,8.72,
thiamine 100 mg Tab [KHKS],6192159,CDM,250,RC,50268-0851-15,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
thiamine 100 mg Tab [KHKS],6192159,CDM,250,RC,50268-0851-15,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
NIFEdipine 90 mg ER Tab [KHKS],6192161,CDM,250,RC,50742-0622-01,NDC,,,Outpatient,1,EA,9.09,,,,80,,7.28,percent of total billed charges,,,,85,7.73,percent of total billed charges,,,77.7,,7.07,percent of total billed charges,,,95,,8.64,percent of total billed charges,,,60,,5.46,percent of total billed charges,,5.46,8.64,
NIFEdipine 90 mg ER Tab [KHKS],6192161,CDM,250,RC,50742-0622-01,NDC,,,Inpatient,1,EA,9.09,,,,80,,7.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.07,percent of total billed charges,,,95,,8.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,8.64,
remdesivir 100 mg Vial [KHKS],6192162,CDM,636,RC,J0248,HCPCS,61958-2901-02,NDC,Outpatient,1,EA,1154.4,,,,80,,923.52,percent of total billed charges,,,,50,3.56,fee schedule,,,77.7,,896.97,percent of total billed charges,,,95,,1096.68,percent of total billed charges,,,60,,692.64,percent of total billed charges,,3.56,1096.68,
remdesivir 100 mg Vial [KHKS],6192162,CDM,636,RC,J0248,HCPCS,61958-2901-02,NDC,Inpatient,1,EA,1154.4,,,,80,,923.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,896.97,percent of total billed charges,,,95,,1096.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1096.68,
dexmedetomidine 100 mcg/mL IV Sol 2 mL [KHKS],6192163,CDM,250,RC,55150-0209-02,NDC,,,Outpatient,2,ML,25.92,,,,80,,20.74,percent of total billed charges,,,,85,22.03,percent of total billed charges,,,77.7,,20.14,percent of total billed charges,,,95,,24.62,percent of total billed charges,,,60,,15.55,percent of total billed charges,,15.55,24.62,
dexmedetomidine 100 mcg/mL IV Sol 2 mL [KHKS],6192163,CDM,250,RC,55150-0209-02,NDC,,,Inpatient,2,ML,25.92,,,,80,,20.74,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,20.14,percent of total billed charges,,,95,,24.62,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,24.62,
heparin 5000 units/mL Inj Sol 1 mL [KHKS],6192166,CDM,636,RC,J1644,HCPCS,63323-0262-26,NDC,Outpatient,1,ML,7.2,,,,80,,5.76,percent of total billed charges,,,,50,0.17,fee schedule,,,77.7,,5.59,percent of total billed charges,,,95,,6.84,percent of total billed charges,,,60,,4.32,percent of total billed charges,,0.17,6.84,
heparin 5000 units/mL Inj Sol 1 mL [KHKS],6192166,CDM,636,RC,J1644,HCPCS,63323-0262-26,NDC,Inpatient,1,ML,7.2,,,,80,,5.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.59,percent of total billed charges,,,95,,6.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.84,
"tetanus/diphtheria/pertussis, acel (Tdap) 5 units-2.5 units-18.5 mcg/0.5 mL IM Susp 0.5 mL Syringe [KHKS]",6192167,CDM,636,RC,58160-0842-52,NDC,,,Outpatient,0.5,ML,159.93,,,,80,,127.94,percent of total billed charges,,,,85,135.94,percent of total billed charges,,,77.7,,124.27,percent of total billed charges,,,95,,151.93,percent of total billed charges,,,60,,95.96,percent of total billed charges,,95.96,151.93,
"tetanus/diphtheria/pertussis, acel (Tdap) 5 units-2.5 units-18.5 mcg/0.5 mL IM Susp 0.5 mL Syringe [KHKS]",6192167,CDM,636,RC,58160-0842-52,NDC,,,Inpatient,0.5,ML,159.93,,,,80,,127.94,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,124.27,percent of total billed charges,,,95,,151.93,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,151.93,
acetaminophen 500 mg/15 mL Oral Liq 237 mL [KHKS],6192168,CDM,250,RC,00904-5847-09,NDC,,,Outpatient,237,ML,12.57,,,,80,,10.06,percent of total billed charges,,,,85,10.68,percent of total billed charges,,,77.7,,9.77,percent of total billed charges,,,95,,11.94,percent of total billed charges,,,60,,7.54,percent of total billed charges,,7.54,11.94,
acetaminophen 500 mg/15 mL Oral Liq 237 mL [KHKS],6192168,CDM,250,RC,00904-5847-09,NDC,,,Inpatient,237,ML,12.57,,,,80,,10.06,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.77,percent of total billed charges,,,95,,11.94,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.94,
venlafaxine 75 mg ER Cap [KHKS],6192169,CDM,250,RC,00904-7077-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
venlafaxine 75 mg ER Cap [KHKS],6192169,CDM,250,RC,00904-7077-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
racepinephrine 2.25% Sol UD [KHKS],6192170,CDM,250,RC,00487-5901-99,NDC,,,Outpatient,1,ML,5.63,,,,80,,4.5,percent of total billed charges,,,,85,4.79,percent of total billed charges,,,77.7,,4.37,percent of total billed charges,,,95,,5.34,percent of total billed charges,,,60,,3.38,percent of total billed charges,,3.38,5.34,
racepinephrine 2.25% Sol UD [KHKS],6192170,CDM,250,RC,00487-5901-99,NDC,,,Inpatient,1,ML,5.63,,,,80,,4.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.37,percent of total billed charges,,,95,,5.34,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.34,
hydrocortisone Top 2.5% Crm 30 gm[KHKS],6192171,CDM,250,RC,00168-0080-31,NDC,,,Outpatient,30,EA,33,,,,80,,26.4,percent of total billed charges,,,,85,28.05,percent of total billed charges,,,77.7,,25.64,percent of total billed charges,,,95,,31.35,percent of total billed charges,,,60,,19.8,percent of total billed charges,,19.8,31.35,
hydrocortisone Top 2.5% Crm 30 gm[KHKS],6192171,CDM,250,RC,00168-0080-31,NDC,,,Inpatient,30,EA,33,,,,80,,26.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,25.64,percent of total billed charges,,,95,,31.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,31.35,
propafenone 225 mg Tab [KHKS],6192173,CDM,250,RC,00591-0583-01,NDC,,,Outpatient,1,EA,6.99,,,,80,,5.59,percent of total billed charges,,,,85,5.94,percent of total billed charges,,,77.7,,5.43,percent of total billed charges,,,95,,6.64,percent of total billed charges,,,60,,4.19,percent of total billed charges,,4.19,6.64,
propafenone 225 mg Tab [KHKS],6192173,CDM,250,RC,00591-0583-01,NDC,,,Inpatient,1,EA,6.99,,,,80,,5.59,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.43,percent of total billed charges,,,95,,6.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.64,
divalproex sodium 250 mg ER Tab [KHKS],6192174,CDM,250,RC,68084-0310-01,NDC,,,Outpatient,1,EA,7.34,,,,80,,5.87,percent of total billed charges,,,,85,6.24,percent of total billed charges,,,77.7,,5.7,percent of total billed charges,,,95,,6.97,percent of total billed charges,,,60,,4.4,percent of total billed charges,,4.4,6.97,
divalproex sodium 250 mg ER Tab [KHKS],6192174,CDM,250,RC,68084-0310-01,NDC,,,Inpatient,1,EA,7.34,,,,80,,5.87,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.7,percent of total billed charges,,,95,,6.97,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.97,
lidocaine Top 4% (MM) 40 mg/mL Sol 50 mL [KHKS],6192175,CDM,250,RC,70954-0518-10,NDC,,,Outpatient,50,ML,193.92,,,,80,,155.14,percent of total billed charges,,,,85,164.83,percent of total billed charges,,,77.7,,150.68,percent of total billed charges,,,95,,184.22,percent of total billed charges,,,60,,116.35,percent of total billed charges,,116.35,184.22,
lidocaine Top 4% (MM) 40 mg/mL Sol 50 mL [KHKS],6192175,CDM,250,RC,70954-0518-10,NDC,,,Inpatient,50,ML,193.92,,,,80,,155.14,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,150.68,percent of total billed charges,,,95,,184.22,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,184.22,
DULoxetine 30 mg Cap [KHKS],6192176,CDM,250,RC,50268-0270-13,NDC,,,Outpatient,1,EA,5.17,,,,80,,4.14,percent of total billed charges,,,,85,4.39,percent of total billed charges,,,77.7,,4.02,percent of total billed charges,,,95,,4.91,percent of total billed charges,,,60,,3.1,percent of total billed charges,,3.1,4.91,
DULoxetine 30 mg Cap [KHKS],6192176,CDM,250,RC,50268-0270-13,NDC,,,Inpatient,1,EA,5.17,,,,80,,4.14,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.02,percent of total billed charges,,,95,,4.91,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.91,
labetalol 5 mg/mL IV Sol 20 mL [KHKS],6192178,CDM,636,RC,J1920,HCPCS,72266-0102-01,NDC,Outpatient,1,ML,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
labetalol 5 mg/mL IV Sol 20 mL [KHKS],6192178,CDM,636,RC,J1920,HCPCS,72266-0102-01,NDC,Inpatient,1,ML,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
dexamethasone 1 mg Tab [KHKS],6192179,CDM,250,RC,00054-8174-25,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
dexamethasone 1 mg Tab [KHKS],6192179,CDM,250,RC,00054-8174-25,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
apixaban 2.5 mg Tab [KHKS],6192180,CDM,250,RC,00003-0893-31,NDC,,,Outpatient,1,EA,31.74,,,,80,,25.39,percent of total billed charges,,,,85,26.98,percent of total billed charges,,,77.7,,24.66,percent of total billed charges,,,95,,30.16,percent of total billed charges,,,60,,19.05,percent of total billed charges,,19.05,30.16,
apixaban 2.5 mg Tab [KHKS],6192180,CDM,250,RC,00003-0893-31,NDC,,,Inpatient,1,EA,31.74,,,,80,,25.39,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,24.66,percent of total billed charges,,,95,,30.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,30.16,
witch hazel topical 50% Pad [KHKS],6192181,CDM,250,RC,50289-3250-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
witch hazel topical 50% Pad [KHKS],6192181,CDM,250,RC,50289-3250-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
tuberculin purified protein derivative 5 TU/0.1 mL ID Sol [KHKS],6192182,CDM,250,RC,49281-0752-21,NDC,,,Outpatient,0.1,ML,33.92,,,,80,,27.13,percent of total billed charges,,,,85,28.83,percent of total billed charges,,,77.7,,26.35,percent of total billed charges,,,95,,32.22,percent of total billed charges,,,60,,20.35,percent of total billed charges,,20.35,32.22,
tuberculin purified protein derivative 5 TU/0.1 mL ID Sol [KHKS],6192182,CDM,250,RC,49281-0752-21,NDC,,,Inpatient,0.1,ML,33.92,,,,80,,27.13,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,26.35,percent of total billed charges,,,95,,32.22,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,32.22,
iron sucrose 20 mg/mL IV Sol 10 mL [KHKS],6192183,CDM,636,RC,J1756,HCPCS,00517-2310-05,NDC,Outpatient,10,ML,442.37,,,,80,,353.89,percent of total billed charges,,,,50,0.15,fee schedule,,,77.7,,343.72,percent of total billed charges,,,95,,420.25,percent of total billed charges,,,60,,265.42,percent of total billed charges,,0.15,420.25,
iron sucrose 20 mg/mL IV Sol 10 mL [KHKS],6192183,CDM,636,RC,J1756,HCPCS,00517-2310-05,NDC,Inpatient,10,ML,442.37,,,,80,,353.89,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,343.72,percent of total billed charges,,,95,,420.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,420.25,
losartan 50 mg Tab [KHKS],6192185,CDM,250,RC,63739-0686-10,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
losartan 50 mg Tab [KHKS],6192185,CDM,250,RC,63739-0686-10,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
diltiazem ER 180 mg Cap [KHKS],6192186,CDM,250,RC,60687-0206-01,NDC,,,Outpatient,1,EA,2.9,,,,80,,2.32,percent of total billed charges,,,,85,2.47,percent of total billed charges,,,77.7,,2.25,percent of total billed charges,,,95,,2.75,percent of total billed charges,,,60,,1.74,percent of total billed charges,,1.74,2.75,
diltiazem ER 180 mg Cap [KHKS],6192186,CDM,250,RC,60687-0206-01,NDC,,,Inpatient,1,EA,2.9,,,,80,,2.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.25,percent of total billed charges,,,95,,2.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.75,
ofloxacin Ophth 0.3% Sol 5 mL [KHKS],6192187,CDM,250,RC,17478-0713-10,NDC,,,Outpatient,5,EA,62.82,,,,80,,50.26,percent of total billed charges,,,,85,53.4,percent of total billed charges,,,77.7,,48.81,percent of total billed charges,,,95,,59.68,percent of total billed charges,,,60,,37.69,percent of total billed charges,,37.69,59.68,
ofloxacin Ophth 0.3% Sol 5 mL [KHKS],6192187,CDM,250,RC,17478-0713-10,NDC,,,Inpatient,5,EA,62.82,,,,80,,50.26,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,48.81,percent of total billed charges,,,95,,59.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,59.68,
Dextrose 5% with 0.45% NaCl IV Sol 1000 mL [KHKS],6192188,CDM,250,RC,00990-7926-09,NDC,,,Outpatient,1000,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,85,16.07,percent of total billed charges,,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,60,,11.34,percent of total billed charges,,11.34,17.96,
Dextrose 5% with 0.45% NaCl IV Sol 1000 mL [KHKS],6192188,CDM,250,RC,00990-7926-09,NDC,,,Inpatient,1000,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.96,
acetaminophen-oxyCODONE 325 mg-5 mg Tab [KHKS],6192189,CDM,250,RC,00406-0512-62,NDC,,,Outpatient,1,EA,4.11,,,,80,,3.28,percent of total billed charges,,,,85,3.49,percent of total billed charges,,,77.7,,3.19,percent of total billed charges,,,95,,3.9,percent of total billed charges,,,60,,2.46,percent of total billed charges,,2.46,3.9,
acetaminophen-oxyCODONE 325 mg-5 mg Tab [KHKS],6192189,CDM,250,RC,00406-0512-62,NDC,,,Inpatient,1,EA,4.11,,,,80,,3.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.19,percent of total billed charges,,,95,,3.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.9,
timolol Ophth 0.5% Sol 5 mL [KHKS],6192190,CDM,250,RC,64980-0514-05,NDC,,,Outpatient,5,EA,51,,,,80,,40.8,percent of total billed charges,,,,85,43.35,percent of total billed charges,,,77.7,,39.63,percent of total billed charges,,,95,,48.45,percent of total billed charges,,,60,,30.6,percent of total billed charges,,30.6,48.45,
timolol Ophth 0.5% Sol 5 mL [KHKS],6192190,CDM,250,RC,64980-0514-05,NDC,,,Inpatient,5,EA,51,,,,80,,40.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,39.63,percent of total billed charges,,,95,,48.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,48.45,
allopurinol 100 mg Tab [KHKS],6192191,CDM,250,RC,16714-0041-10,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
allopurinol 100 mg Tab [KHKS],6192191,CDM,250,RC,16714-0041-10,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
"EPINEPHrine-lidocaine 1:200,000-2% PF Inj Sol 20 mL [KHKS]",6192192,CDM,636,RC,J2004,HCPCS,63323-0489-27,NDC,Outpatient,20,ML,70.2,,,,80,,56.16,percent of total billed charges,,,,85,59.67,percent of total billed charges,,,77.7,,54.55,percent of total billed charges,,,95,,66.69,percent of total billed charges,,,60,,42.12,percent of total billed charges,,42.12,66.69,
"EPINEPHrine-lidocaine 1:200,000-2% PF Inj Sol 20 mL [KHKS]",6192192,CDM,636,RC,J2004,HCPCS,63323-0489-27,NDC,Inpatient,20,ML,70.2,,,,80,,56.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,54.55,percent of total billed charges,,,95,,66.69,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,66.69,
gentamicin 40 mg/mL IV Inj Sol 2 mL [KHKS],6192193,CDM,636,RC,J1580,HCPCS,63323-0010-02,NDC,Outpatient,2,ML,12.74,,,,80,,10.2,percent of total billed charges,,,,50,2.11,fee schedule,,,77.7,,9.9,percent of total billed charges,,,95,,12.11,percent of total billed charges,,,60,,7.65,percent of total billed charges,,2.11,12.11,
gentamicin 40 mg/mL IV Inj Sol 2 mL [KHKS],6192193,CDM,636,RC,J1580,HCPCS,63323-0010-02,NDC,Inpatient,2,ML,12.74,,,,80,,10.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.9,percent of total billed charges,,,95,,12.11,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,12.11,
enoxaparin 40 mg/0.4 mL Sol Syringe [KHKS],6192194,CDM,636,RC,J1650,HCPCS,71288-0410-83,NDC,Outpatient,0.4,ML,21.6,,,,80,,17.28,percent of total billed charges,,,,50,0.52,fee schedule,,,77.7,,16.78,percent of total billed charges,,,95,,20.52,percent of total billed charges,,,60,,12.96,percent of total billed charges,,0.52,20.52,
enoxaparin 40 mg/0.4 mL Sol Syringe [KHKS],6192194,CDM,636,RC,J1650,HCPCS,71288-0410-83,NDC,Inpatient,0.4,ML,21.6,,,,80,,17.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,16.78,percent of total billed charges,,,95,,20.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,20.52,
Dextrose 5% in Water IV Sol 500 mL [KHKS],6192196,CDM,636,RC,J7060,HCPCS,00990-7922-03,NDC,Outpatient,500,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,50,1.12,fee schedule,,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,60,,11.34,percent of total billed charges,,1.12,17.96,
Dextrose 5% in Water IV Sol 500 mL [KHKS],6192196,CDM,636,RC,J7060,HCPCS,00990-7922-03,NDC,Inpatient,500,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.96,
nitroglycerin Film-ER,6192197,CDM,250,RC,00378-9104-93,NDC,,,Outpatient,1,EA,5.71,,,,80,,4.56,percent of total billed charges,,,,85,4.85,percent of total billed charges,,,77.7,,4.43,percent of total billed charges,,,95,,5.42,percent of total billed charges,,,60,,3.42,percent of total billed charges,,3.42,5.42,
nitroglycerin Film-ER,6192197,CDM,250,RC,00378-9104-93,NDC,,,Inpatient,1,EA,5.71,,,,80,,4.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.43,percent of total billed charges,,,95,,5.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.42,
desmopressin 4 mcg/mL IV Sol 1 mL [KHKS],6192198,CDM,636,RC,J2597,HCPCS,69918-0899-10,NDC,Outpatient,1,ML,211.66,,,,80,,169.32,percent of total billed charges,,,,50,4.71,fee schedule,,,77.7,,164.46,percent of total billed charges,,,95,,201.07,percent of total billed charges,,,60,,126.99,percent of total billed charges,,4.71,201.07,
desmopressin 4 mcg/mL IV Sol 1 mL [KHKS],6192198,CDM,636,RC,J2597,HCPCS,69918-0899-10,NDC,Inpatient,1,ML,211.66,,,,80,,169.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,164.46,percent of total billed charges,,,95,,201.07,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,201.07,
levalbuterol 1.25 mg/3 mL Inh Sol [KHKS],6192199,CDM,250,RC,76204-0900-01,NDC,,,Outpatient,3,ML,6,,,,80,,4.8,percent of total billed charges,,,,85,5.1,percent of total billed charges,,,77.7,,4.66,percent of total billed charges,,,95,,5.7,percent of total billed charges,,,60,,3.6,percent of total billed charges,,3.6,5.7,
levalbuterol 1.25 mg/3 mL Inh Sol [KHKS],6192199,CDM,250,RC,76204-0900-01,NDC,,,Inpatient,3,ML,6,,,,80,,4.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.66,percent of total billed charges,,,95,,5.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.7,
sodium chloride 1 g Tab [KHKS],6192201,CDM,250,RC,69367-0220-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
sodium chloride 1 g Tab [KHKS],6192201,CDM,250,RC,69367-0220-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
ketamine 50 mg/mL Inj Sol 10 mL [KHKS],6192202,CDM,250,RC,67457-0001-10,NDC,,,Outpatient,10,ML,26.33,,,,80,,21.06,percent of total billed charges,,,,85,22.38,percent of total billed charges,,,77.7,,20.45,percent of total billed charges,,,95,,25.01,percent of total billed charges,,,60,,15.8,percent of total billed charges,,15.8,25.01,
ketamine 50 mg/mL Inj Sol 10 mL [KHKS],6192202,CDM,250,RC,67457-0001-10,NDC,,,Inpatient,10,ML,26.33,,,,80,,21.06,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,20.45,percent of total billed charges,,,95,,25.01,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,25.01,
fentaNYL 50 mcg/hr Patch [KHKS],6192203,CDM,250,RC,47781-0426-47,NDC,,,Outpatient,1,EA,116.65,,,,80,,93.32,percent of total billed charges,,,,85,99.15,percent of total billed charges,,,77.7,,90.63,percent of total billed charges,,,95,,110.81,percent of total billed charges,,,60,,69.99,percent of total billed charges,,69.99,110.81,
fentaNYL 50 mcg/hr Patch [KHKS],6192203,CDM,250,RC,47781-0426-47,NDC,,,Inpatient,1,EA,116.65,,,,80,,93.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,90.63,percent of total billed charges,,,95,,110.81,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,110.81,
hydrocortisone 25 mg Supp [KHKS],6192204,CDM,250,RC,69367-0243-24,NDC,,,Outpatient,1,EA,54.87,,,,80,,43.89,percent of total billed charges,,,,85,46.64,percent of total billed charges,,,77.7,,42.63,percent of total billed charges,,,95,,52.13,percent of total billed charges,,,60,,32.92,percent of total billed charges,,32.92,52.13,
hydrocortisone 25 mg Supp [KHKS],6192204,CDM,250,RC,69367-0243-24,NDC,,,Inpatient,1,EA,54.87,,,,80,,43.89,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,42.63,percent of total billed charges,,,95,,52.13,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,52.13,
amiodarone 200 mg Tab [KHKS],6192205,CDM,250,RC,00245-0147-01,NDC,,,Outpatient,1,EA,23.83,,,,80,,19.07,percent of total billed charges,,,,85,20.26,percent of total billed charges,,,77.7,,18.52,percent of total billed charges,,,95,,22.64,percent of total billed charges,,,60,,14.3,percent of total billed charges,,14.3,22.64,
amiodarone 200 mg Tab [KHKS],6192205,CDM,250,RC,00245-0147-01,NDC,,,Inpatient,1,EA,23.83,,,,80,,19.07,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,18.52,percent of total billed charges,,,95,,22.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,22.64,
"rivastigmine 4.6 mg/24 hr TD film, ER [KHKS]",6192206,CDM,250,RC,16714-0115-02,NDC,,,Outpatient,1,EA,49.84,,,,80,,39.87,percent of total billed charges,,,,85,42.36,percent of total billed charges,,,77.7,,38.72,percent of total billed charges,,,95,,47.35,percent of total billed charges,,,60,,29.9,percent of total billed charges,,29.9,47.35,
"rivastigmine 4.6 mg/24 hr TD film, ER [KHKS]",6192206,CDM,250,RC,16714-0115-02,NDC,,,Inpatient,1,EA,49.84,,,,80,,39.87,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,38.72,percent of total billed charges,,,95,,47.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,47.35,
naloxone 0.4 mg/mL Inj Sol 1 mL [KHKS],6192207,CDM,636,RC,J2310,HCPCS,17478-0041-01,NDC,Outpatient,1,ML,56.99,,,,80,,45.59,percent of total billed charges,,,,50,6.62,fee schedule,,,77.7,,44.28,percent of total billed charges,,,95,,54.14,percent of total billed charges,,,60,,34.19,percent of total billed charges,,6.62,54.14,
naloxone 0.4 mg/mL Inj Sol 1 mL [KHKS],6192207,CDM,636,RC,J2310,HCPCS,17478-0041-01,NDC,Inpatient,1,ML,56.99,,,,80,,45.59,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,44.28,percent of total billed charges,,,95,,54.14,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,54.14,
pantoprazole 40 mg IV Inj [KHKS],6192208,CDM,636,RC,J2470,HCPCS,55150-0202-10,NDC,Outpatient,1,EA,25.5,,,,80,,20.4,percent of total billed charges,,,,85,21.68,percent of total billed charges,,,77.7,,19.81,percent of total billed charges,,,95,,24.23,percent of total billed charges,,,60,,15.3,percent of total billed charges,,15.3,24.23,
pantoprazole 40 mg IV Inj [KHKS],6192208,CDM,636,RC,J2470,HCPCS,55150-0202-10,NDC,Inpatient,1,EA,25.5,,,,80,,20.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.81,percent of total billed charges,,,95,,24.23,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,24.23,
aspirin 81 mg Chew Tab [KHKS],6192209,CDM,250,RC,66553-0002-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
aspirin 81 mg Chew Tab [KHKS],6192209,CDM,250,RC,66553-0002-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
hepatitis B pediatric vaccine 10 mcg/0.5 mL Susp 0.5 mL [KHKS],6192210,CDM,636,RC,58160-0820-52,NDC,,,Outpatient,0.5,ML,0.01,,,,80,,0.01,percent of total billed charges,,,,85,0.01,percent of total billed charges,,,77.7,,0.01,percent of total billed charges,,,95,,0.01,percent of total billed charges,,,60,,0.01,percent of total billed charges,,0.01,0.01,
hepatitis B pediatric vaccine 10 mcg/0.5 mL Susp 0.5 mL [KHKS],6192210,CDM,636,RC,58160-0820-52,NDC,,,Inpatient,0.5,ML,0.01,,,,80,,0.01,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.01,percent of total billed charges,,,95,,0.01,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,0.01,
ampicillin-sulbactam 3 g Inj Pow [KHKS],6192211,CDM,636,RC,J0295,HCPCS,55150-0117-20,NDC,Outpatient,1,EA,43.8,,,,80,,35.04,percent of total billed charges,,,,50,1.44,fee schedule,,,77.7,,34.03,percent of total billed charges,,,95,,41.61,percent of total billed charges,,,60,,26.28,percent of total billed charges,,1.44,41.61,
ampicillin-sulbactam 3 g Inj Pow [KHKS],6192211,CDM,636,RC,J0295,HCPCS,55150-0117-20,NDC,Inpatient,1,EA,43.8,,,,80,,35.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,34.03,percent of total billed charges,,,95,,41.61,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,41.61,
benzonatate 100 mg Cap [KHKS],6192212,CDM,250,RC,00904-6564-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
benzonatate 100 mg Cap [KHKS],6192212,CDM,250,RC,00904-6564-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
sterile water IRRIG Sol 1000 mL [KHKS],6192213,CDM,250,RC,00990-7139-09,NDC,,,Outpatient,1000,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,85,16.07,percent of total billed charges,,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,60,,11.34,percent of total billed charges,,11.34,17.96,
sterile water IRRIG Sol 1000 mL [KHKS],6192213,CDM,250,RC,00990-7139-09,NDC,,,Inpatient,1000,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.96,
tiotropium 18 mcg Inh Cap [KHKS],6192214,CDM,250,RC,00597-0075-75,NDC,,,Outpatient,5,EA,265.84,,,,80,,212.67,percent of total billed charges,,,,85,225.96,percent of total billed charges,,,77.7,,206.56,percent of total billed charges,,,95,,252.55,percent of total billed charges,,,60,,159.5,percent of total billed charges,,159.5,252.55,
tiotropium 18 mcg Inh Cap [KHKS],6192214,CDM,250,RC,00597-0075-75,NDC,,,Inpatient,5,EA,265.84,,,,80,,212.67,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,206.56,percent of total billed charges,,,95,,252.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,252.55,
gentamicin Ophth 0.3% Sol 5 mL [KHKS],6192215,CDM,250,RC,60758-0188-05,NDC,,,Outpatient,5,EA,57.54,,,,80,,46.03,percent of total billed charges,,,,85,48.91,percent of total billed charges,,,77.7,,44.71,percent of total billed charges,,,95,,54.66,percent of total billed charges,,,60,,34.52,percent of total billed charges,,34.52,54.66,
gentamicin Ophth 0.3% Sol 5 mL [KHKS],6192215,CDM,250,RC,60758-0188-05,NDC,,,Inpatient,5,EA,57.54,,,,80,,46.03,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,44.71,percent of total billed charges,,,95,,54.66,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,54.66,
iohexol 350 mg/mL Inj Sol 100 mL [KHKS],6192216,CDM,636,RC,Q9967,HCPCS,00407-1414-91,NDC,Outpatient,100,ML,500,,,,80,,400,percent of total billed charges,,,,50,2.53,fee schedule,,,77.7,,388.5,percent of total billed charges,,,95,,475,percent of total billed charges,,,60,,300,percent of total billed charges,,2.53,475,
iohexol 350 mg/mL Inj Sol 100 mL [KHKS],6192216,CDM,636,RC,Q9967,HCPCS,00407-1414-91,NDC,Inpatient,100,ML,500,,,,80,,400,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,388.5,percent of total billed charges,,,95,,475,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,475,
Sodium Chloride 0.9% IV Sol 1000 mL [KHKS],6192217,CDM,636,RC,J7030,HCPCS,00990-7983-09,NDC,Outpatient,1000,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,50,1.7,fee schedule,,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,60,,11.34,percent of total billed charges,,1.7,17.96,
Sodium Chloride 0.9% IV Sol 1000 mL [KHKS],6192217,CDM,636,RC,J7030,HCPCS,00990-7983-09,NDC,Inpatient,1000,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.96,
lidocaine 1% PF Inj Sol 5 mL [KHKS],6192218,CDM,250,RC,00143-9595-25,NDC,,,Outpatient,5,ML,8.86,,,,80,,7.08,percent of total billed charges,,,,85,7.53,percent of total billed charges,,,77.7,,6.88,percent of total billed charges,,,95,,8.41,percent of total billed charges,,,60,,5.31,percent of total billed charges,,5.31,8.41,
lidocaine 1% PF Inj Sol 5 mL [KHKS],6192218,CDM,250,RC,00143-9595-25,NDC,,,Inpatient,5,ML,8.86,,,,80,,7.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.88,percent of total billed charges,,,95,,8.41,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,8.41,
metoclopramide 5 mg/5 mL Oral Syrup [KHKS],6192219,CDM,250,RC,00121-1576-10,NDC,,,Outpatient,10,ML,12.68,,,,80,,10.15,percent of total billed charges,,,,85,10.78,percent of total billed charges,,,77.7,,9.86,percent of total billed charges,,,95,,12.05,percent of total billed charges,,,60,,7.61,percent of total billed charges,,7.61,12.05,
metoclopramide 5 mg/5 mL Oral Syrup [KHKS],6192219,CDM,250,RC,00121-1576-10,NDC,,,Inpatient,10,ML,12.68,,,,80,,10.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.86,percent of total billed charges,,,95,,12.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,12.05,
vancomycin 125 mg Cap [KHKS],6192220,CDM,250,RC,47781-0729-02,NDC,,,Outpatient,1,EA,93.92,,,,80,,75.13,percent of total billed charges,,,,85,79.83,percent of total billed charges,,,77.7,,72.97,percent of total billed charges,,,95,,89.22,percent of total billed charges,,,60,,56.35,percent of total billed charges,,56.35,89.22,
vancomycin 125 mg Cap [KHKS],6192220,CDM,250,RC,47781-0729-02,NDC,,,Inpatient,1,EA,93.92,,,,80,,75.13,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,72.97,percent of total billed charges,,,95,,89.22,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,89.22,
mupirocin Top 2% Oint 22 gm [KHKS],6192221,CDM,250,RC,68462-0180-22,NDC,,,Outpatient,22,EA,128.25,,,,80,,102.6,percent of total billed charges,,,,85,109.01,percent of total billed charges,,,77.7,,99.65,percent of total billed charges,,,95,,121.84,percent of total billed charges,,,60,,76.95,percent of total billed charges,,76.95,121.84,
mupirocin Top 2% Oint 22 gm [KHKS],6192221,CDM,250,RC,68462-0180-22,NDC,,,Inpatient,22,EA,128.25,,,,80,,102.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,99.65,percent of total billed charges,,,95,,121.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,121.84,
sodium polystyrene sulfonate compounding Pwdr [KHKS],6192222,CDM,250,RC,10702-0036-15,NDC,,,Outpatient,15,EA,40.89,,,,80,,32.71,percent of total billed charges,,,,85,34.76,percent of total billed charges,,,77.7,,31.77,percent of total billed charges,,,95,,38.85,percent of total billed charges,,,60,,24.53,percent of total billed charges,,24.53,38.85,
sodium polystyrene sulfonate compounding Pwdr [KHKS],6192222,CDM,250,RC,10702-0036-15,NDC,,,Inpatient,15,EA,40.89,,,,80,,32.71,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,31.77,percent of total billed charges,,,95,,38.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,38.85,
promethazine 50 mg/mL Inj Sol 1 mL [KHKS],6192223,CDM,636,RC,J2550,HCPCS,00641-0949-35,NDC,Outpatient,1,ML,9.06,,,,80,,7.24,percent of total billed charges,,,,50,2.07,fee schedule,,,77.7,,7.04,percent of total billed charges,,,95,,8.6,percent of total billed charges,,,60,,5.43,percent of total billed charges,,2.07,8.6,
promethazine 50 mg/mL Inj Sol 1 mL [KHKS],6192223,CDM,636,RC,J2550,HCPCS,00641-0949-35,NDC,Inpatient,1,ML,9.06,,,,80,,7.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.04,percent of total billed charges,,,95,,8.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,8.6,
atropine/hyoscyamine/PB/scopolamine Oral Elix 120 mL [KHKS],6192224,CDM,250,RC,59212-0423-04,NDC,,,Outpatient,120,ML,999,,,,80,,799.2,percent of total billed charges,,,,85,849.15,percent of total billed charges,,,77.7,,776.22,percent of total billed charges,,,95,,949.05,percent of total billed charges,,,60,,599.4,percent of total billed charges,,599.4,949.05,
atropine/hyoscyamine/PB/scopolamine Oral Elix 120 mL [KHKS],6192224,CDM,250,RC,59212-0423-04,NDC,,,Inpatient,120,ML,999,,,,80,,799.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,776.22,percent of total billed charges,,,95,,949.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,949.05,
NIFEdipine 10 mg Cap [KHKS],6192225,CDM,250,RC,69315-0211-01,NDC,,,Outpatient,1,EA,3.21,,,,80,,2.56,percent of total billed charges,,,,85,2.73,percent of total billed charges,,,77.7,,2.49,percent of total billed charges,,,95,,3.04,percent of total billed charges,,,60,,1.92,percent of total billed charges,,1.92,3.04,
NIFEdipine 10 mg Cap [KHKS],6192225,CDM,250,RC,69315-0211-01,NDC,,,Inpatient,1,EA,3.21,,,,80,,2.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.49,percent of total billed charges,,,95,,3.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.04,
glipiZIDE 5 mg Tab [KHKS],6192226,CDM,250,RC,00904-6637-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
glipiZIDE 5 mg Tab [KHKS],6192226,CDM,250,RC,00904-6637-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
sotalol 80 mg Tab [KHKS],6192227,CDM,250,RC,68084-0654-01,NDC,,,Outpatient,1,EA,6.96,,,,80,,5.57,percent of total billed charges,,,,85,5.92,percent of total billed charges,,,77.7,,5.41,percent of total billed charges,,,95,,6.61,percent of total billed charges,,,60,,4.18,percent of total billed charges,,4.18,6.61,
sotalol 80 mg Tab [KHKS],6192227,CDM,250,RC,68084-0654-01,NDC,,,Inpatient,1,EA,6.96,,,,80,,5.57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.41,percent of total billed charges,,,95,,6.61,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.61,
bumetanide 0.25 mg/mL Inj Sol 4 mL [KHKS],6192229,CDM,636,RC,00641-6161-10,NDC,,,Outpatient,4,ML,8.19,,,,80,,6.55,percent of total billed charges,,,,85,6.96,percent of total billed charges,,,77.7,,6.36,percent of total billed charges,,,95,,7.78,percent of total billed charges,,,60,,4.91,percent of total billed charges,,4.91,7.78,
bumetanide 0.25 mg/mL Inj Sol 4 mL [KHKS],6192229,CDM,636,RC,00641-6161-10,NDC,,,Inpatient,4,ML,8.19,,,,80,,6.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.36,percent of total billed charges,,,95,,7.78,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.78,
lamoTRIgine 100 mg Tab [KHKS],6192230,CDM,250,RC,68084-0319-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
lamoTRIgine 100 mg Tab [KHKS],6192230,CDM,250,RC,68084-0319-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
colchicine 0.6 mg Tab [KHKS],6192231,CDM,250,RC,00904-7120-04,NDC,,,Outpatient,1,EA,17.27,,,,80,,13.82,percent of total billed charges,,,,85,14.68,percent of total billed charges,,,77.7,,13.42,percent of total billed charges,,,95,,16.41,percent of total billed charges,,,60,,10.36,percent of total billed charges,,10.36,16.41,
colchicine 0.6 mg Tab [KHKS],6192231,CDM,250,RC,00904-7120-04,NDC,,,Inpatient,1,EA,17.27,,,,80,,13.82,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,13.42,percent of total billed charges,,,95,,16.41,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,16.41,
isosorbide mononitrate 30 mg ER Tab [KHKS],6192232,CDM,250,RC,50742-0175-01,NDC,,,Outpatient,1,EA,10.06,,,,80,,8.05,percent of total billed charges,,,,85,8.55,percent of total billed charges,,,77.7,,7.81,percent of total billed charges,,,95,,9.55,percent of total billed charges,,,60,,6.03,percent of total billed charges,,6.03,9.55,
isosorbide mononitrate 30 mg ER Tab [KHKS],6192232,CDM,250,RC,50742-0175-01,NDC,,,Inpatient,1,EA,10.06,,,,80,,8.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.81,percent of total billed charges,,,95,,9.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.55,
ertapenem 1 g IV Inj Sol[KHKS],6192233,CDM,636,RC,J1335,HCPCS,55150-0282-09,NDC,Outpatient,1,EA,288,,,,80,,230.4,percent of total billed charges,,,,50,11.61,fee schedule,,,77.7,,223.78,percent of total billed charges,,,95,,273.6,percent of total billed charges,,,60,,172.8,percent of total billed charges,,11.61,273.6,
ertapenem 1 g IV Inj Sol[KHKS],6192233,CDM,636,RC,J1335,HCPCS,55150-0282-09,NDC,Inpatient,1,EA,288,,,,80,,230.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,223.78,percent of total billed charges,,,95,,273.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,273.6,
Dextrose 5% with 0.45% NaCl IV Sol 500 mL [KHKS],6192234,CDM,250,RC,00990-7926-03,NDC,,,Outpatient,500,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,85,16.07,percent of total billed charges,,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,60,,11.34,percent of total billed charges,,11.34,17.96,
Dextrose 5% with 0.45% NaCl IV Sol 500 mL [KHKS],6192234,CDM,250,RC,00990-7926-03,NDC,,,Inpatient,500,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.96,
methylPREDNISolone sodium succinate 125 mg PF Pow [KHKS],6192235,CDM,636,RC,J2919,HCPCS,00009-0047-26,NDC,Outpatient,1,EA,35.05,,,,80,,28.04,percent of total billed charges,,,,85,29.79,percent of total billed charges,,,77.7,,27.23,percent of total billed charges,,,95,,33.3,percent of total billed charges,,,60,,21.03,percent of total billed charges,,21.03,33.3,
methylPREDNISolone sodium succinate 125 mg PF Pow [KHKS],6192235,CDM,636,RC,J2919,HCPCS,00009-0047-26,NDC,Inpatient,1,EA,35.05,,,,80,,28.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,27.23,percent of total billed charges,,,95,,33.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,33.3,
"penicillin G benzathine 1,200,000 units/2 mL Sus [KHKS]",6192236,CDM,636,RC,J0561,HCPCS,60793-0701-10,NDC,Outpatient,2,ML,684.13,,,,80,,547.3,percent of total billed charges,,,,50,13.68,fee schedule,,,77.7,,531.57,percent of total billed charges,,,95,,649.92,percent of total billed charges,,,60,,410.48,percent of total billed charges,,13.68,649.92,
"penicillin G benzathine 1,200,000 units/2 mL Sus [KHKS]",6192236,CDM,636,RC,J0561,HCPCS,60793-0701-10,NDC,Inpatient,2,ML,684.13,,,,80,,547.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,531.57,percent of total billed charges,,,95,,649.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,649.92,
fosphenytoin (PE) 100 mg/2 mL Inj Sol [KHKS],6192237,CDM,636,RC,Q2009,HCPCS,00069-5471-02,NDC,Outpatient,2,ML,96.39,,,,80,,77.11,percent of total billed charges,,,,50,2.92,fee schedule,,,77.7,,74.9,percent of total billed charges,,,95,,91.57,percent of total billed charges,,,60,,57.83,percent of total billed charges,,2.92,91.57,
fosphenytoin (PE) 100 mg/2 mL Inj Sol [KHKS],6192237,CDM,636,RC,Q2009,HCPCS,00069-5471-02,NDC,Inpatient,2,ML,96.39,,,,80,,77.11,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,74.9,percent of total billed charges,,,95,,91.57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,91.57,
vasopressin 20 units/mL Sol [KHKS],6192238,CDM,636,RC,J2598,HCPCS,42023-0164-10,NDC,Outpatient,1,ML,471.48,,,,80,,377.18,percent of total billed charges,,,,85,400.76,percent of total billed charges,,,77.7,,366.34,percent of total billed charges,,,95,,447.9,percent of total billed charges,,,60,,282.89,percent of total billed charges,,282.89,447.9,
vasopressin 20 units/mL Sol [KHKS],6192238,CDM,636,RC,J2598,HCPCS,42023-0164-10,NDC,Inpatient,1,ML,471.48,,,,80,,377.18,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,366.34,percent of total billed charges,,,95,,447.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,447.9,
oseltamivir 6 mg/mL 60 mL [KHKS],6192239,CDM,250,RC,68180-0678-01,NDC,,,Outpatient,60,ML,368.42,,,,80,,294.73,percent of total billed charges,,,,85,313.16,percent of total billed charges,,,77.7,,286.26,percent of total billed charges,,,95,,349.99,percent of total billed charges,,,60,,221.05,percent of total billed charges,,221.05,349.99,
oseltamivir 6 mg/mL 60 mL [KHKS],6192239,CDM,250,RC,68180-0678-01,NDC,,,Inpatient,60,ML,368.42,,,,80,,294.73,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,286.26,percent of total billed charges,,,95,,349.99,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,349.99,
ciprofloxacin-dexamethasone 0.3%-0.1% OTIC Susp 7.5 mL [KHKS],6192240,CDM,250,RC,43598-0326-75,NDC,,,Outpatient,7.5,EA,497.69,,,,80,,398.15,percent of total billed charges,,,,85,423.04,percent of total billed charges,,,77.7,,386.7,percent of total billed charges,,,95,,472.8,percent of total billed charges,,,60,,298.61,percent of total billed charges,,298.61,472.8,
ciprofloxacin-dexamethasone 0.3%-0.1% OTIC Susp 7.5 mL [KHKS],6192240,CDM,250,RC,43598-0326-75,NDC,,,Inpatient,7.5,EA,497.69,,,,80,,398.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,386.7,percent of total billed charges,,,95,,472.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,472.8,
codeine-guaiFENesin 10 mg-100 mg/5 mL Oral Syrup 118 mL [KHKS],6192241,CDM,250,RC,50383-0087-04,NDC,,,Outpatient,118,ML,41.7,,,,80,,33.36,percent of total billed charges,,,,85,35.45,percent of total billed charges,,,77.7,,32.4,percent of total billed charges,,,95,,39.62,percent of total billed charges,,,60,,25.02,percent of total billed charges,,25.02,39.62,
codeine-guaiFENesin 10 mg-100 mg/5 mL Oral Syrup 118 mL [KHKS],6192241,CDM,250,RC,50383-0087-04,NDC,,,Inpatient,118,ML,41.7,,,,80,,33.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,32.4,percent of total billed charges,,,95,,39.62,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,39.62,
lithium 150 mg Cap [KHKS],6192242,CDM,250,RC,00054-8526-25,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
lithium 150 mg Cap [KHKS],6192242,CDM,250,RC,00054-8526-25,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
"heparin 25,000 units in 500 mL D5W PREMIX [KHKS]",6192243,CDM,636,RC,J1644,HCPCS,00264-9577-10,NDC,Outpatient,500,ML,56.12,,,,80,,44.9,percent of total billed charges,,,,50,0.17,fee schedule,,,77.7,,43.61,percent of total billed charges,,,95,,53.32,percent of total billed charges,,,60,,33.67,percent of total billed charges,,0.17,53.32,
"heparin 25,000 units in 500 mL D5W PREMIX [KHKS]",6192243,CDM,636,RC,J1644,HCPCS,00264-9577-10,NDC,Inpatient,500,ML,56.12,,,,80,,44.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,43.61,percent of total billed charges,,,95,,53.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,53.32,
betamethasone acetate-betamethasone sodium phosphate 3 mg-3 mg Inj Susp 5 mL [KHKS],6192244,CDM,636,RC,J0702,HCPCS,00517-0720-01,NDC,Outpatient,5,ML,188.67,,,,80,,150.94,percent of total billed charges,,,,50,4.38,fee schedule,,,77.7,,146.6,percent of total billed charges,,,95,,179.24,percent of total billed charges,,,60,,113.2,percent of total billed charges,,4.38,179.24,
betamethasone acetate-betamethasone sodium phosphate 3 mg-3 mg Inj Susp 5 mL [KHKS],6192244,CDM,636,RC,J0702,HCPCS,00517-0720-01,NDC,Inpatient,5,ML,188.67,,,,80,,150.94,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,146.6,percent of total billed charges,,,95,,179.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,179.24,
"bupivacaine-EPINEPHrine 0.25%-1:200,000 PF Inj Sol 10 mL [KHKS]",6192245,CDM,250,RC,63323-0468-17,NDC,,,Outpatient,10,ML,20.92,,,,80,,16.73,percent of total billed charges,,,,85,17.78,percent of total billed charges,,,77.7,,16.25,percent of total billed charges,,,95,,19.87,percent of total billed charges,,,60,,12.55,percent of total billed charges,,12.55,19.87,
"bupivacaine-EPINEPHrine 0.25%-1:200,000 PF Inj Sol 10 mL [KHKS]",6192245,CDM,250,RC,63323-0468-17,NDC,,,Inpatient,10,ML,20.92,,,,80,,16.73,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,16.25,percent of total billed charges,,,95,,19.87,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,19.87,
revefenacin 175 mcg/3 mL Sol [KHKS],6192247,CDM,250,RC,49502-0806-93,NDC,,,Outpatient,1,ML,48.64,,,,80,,38.91,percent of total billed charges,,,,85,41.34,percent of total billed charges,,,77.7,,37.79,percent of total billed charges,,,95,,46.21,percent of total billed charges,,,60,,29.18,percent of total billed charges,,29.18,46.21,
revefenacin 175 mcg/3 mL Sol [KHKS],6192247,CDM,250,RC,49502-0806-93,NDC,,,Inpatient,1,ML,48.64,,,,80,,38.91,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,37.79,percent of total billed charges,,,95,,46.21,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,46.21,
cephalexin 250 mg/5 mL Oral Liq 100 mL [KHKS],6192248,CDM,250,RC,68180-0441-01,NDC,,,Outpatient,100,ML,86.25,,,,80,,69,percent of total billed charges,,,,85,73.31,percent of total billed charges,,,77.7,,67.02,percent of total billed charges,,,95,,81.94,percent of total billed charges,,,60,,51.75,percent of total billed charges,,51.75,81.94,
cephalexin 250 mg/5 mL Oral Liq 100 mL [KHKS],6192248,CDM,250,RC,68180-0441-01,NDC,,,Inpatient,100,ML,86.25,,,,80,,69,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,67.02,percent of total billed charges,,,95,,81.94,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,81.94,
nafcillin 2 g IV Inj Sol [KHKS],6192249,CDM,250,RC,55150-0123-16,NDC,,,Outpatient,1,EA,84.83,,,,80,,67.86,percent of total billed charges,,,,85,72.11,percent of total billed charges,,,77.7,,65.91,percent of total billed charges,,,95,,80.58,percent of total billed charges,,,60,,50.9,percent of total billed charges,,50.9,80.58,
nafcillin 2 g IV Inj Sol [KHKS],6192249,CDM,250,RC,55150-0123-16,NDC,,,Inpatient,1,EA,84.83,,,,80,,67.86,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,65.91,percent of total billed charges,,,95,,80.58,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,80.58,
metoprolol tartrate 1 mg/mL Inj Sol [KHKS],6192250,CDM,250,RC,72611-0740-10,NDC,,,Outpatient,5,ML,3.53,,,,80,,2.82,percent of total billed charges,,,,85,3,percent of total billed charges,,,77.7,,2.74,percent of total billed charges,,,95,,3.35,percent of total billed charges,,,60,,2.12,percent of total billed charges,,2.12,3.35,
metoprolol tartrate 1 mg/mL Inj Sol [KHKS],6192250,CDM,250,RC,72611-0740-10,NDC,,,Inpatient,5,ML,3.53,,,,80,,2.82,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.74,percent of total billed charges,,,95,,3.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.35,
oxytocin 10 units/mL Inj Sol 1 mL [KHKS],6192251,CDM,636,RC,J2590,HCPCS,63323-0012-11,NDC,Outpatient,1,ML,10.8,,,,80,,8.64,percent of total billed charges,,,,50,0.53,fee schedule,,,77.7,,8.39,percent of total billed charges,,,95,,10.26,percent of total billed charges,,,60,,6.48,percent of total billed charges,,0.53,10.26,
oxytocin 10 units/mL Inj Sol 1 mL [KHKS],6192251,CDM,636,RC,J2590,HCPCS,63323-0012-11,NDC,Inpatient,1,ML,10.8,,,,80,,8.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.39,percent of total billed charges,,,95,,10.26,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.26,
sodium chloride 0.9% IRRIGATION Sol 3000 mL [KHKS],6192252,CDM,250,RC,00990-7972-08,NDC,,,Outpatient,3000,ML,29.6,,,,80,,23.68,percent of total billed charges,,,,85,25.16,percent of total billed charges,,,77.7,,23,percent of total billed charges,,,95,,28.12,percent of total billed charges,,,60,,17.76,percent of total billed charges,,17.76,28.12,
sodium chloride 0.9% IRRIGATION Sol 3000 mL [KHKS],6192252,CDM,250,RC,00990-7972-08,NDC,,,Inpatient,3000,ML,29.6,,,,80,,23.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,23,percent of total billed charges,,,95,,28.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,28.12,
citalopram 20 mg Tab [KHKS],6192254,CDM,250,RC,00904-6085-61,NDC,,,Outpatient,1,EA,8.08,,,,80,,6.46,percent of total billed charges,,,,85,6.87,percent of total billed charges,,,77.7,,6.28,percent of total billed charges,,,95,,7.68,percent of total billed charges,,,60,,4.85,percent of total billed charges,,4.85,7.68,
citalopram 20 mg Tab [KHKS],6192254,CDM,250,RC,00904-6085-61,NDC,,,Inpatient,1,EA,8.08,,,,80,,6.46,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.28,percent of total billed charges,,,95,,7.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.68,
DAPTOmycin 500 mg IV Inj Sol [KHKS],6192255,CDM,636,RC,J0878,HCPCS,00703-0125-01,NDC,Outpatient,1,EA,283.5,,,,80,,226.8,percent of total billed charges,,,,50,0.13,fee schedule,,,77.7,,220.28,percent of total billed charges,,,95,,269.33,percent of total billed charges,,,60,,170.1,percent of total billed charges,,0.13,269.33,
DAPTOmycin 500 mg IV Inj Sol [KHKS],6192255,CDM,636,RC,J0878,HCPCS,00703-0125-01,NDC,Inpatient,1,EA,283.5,,,,80,,226.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,220.28,percent of total billed charges,,,95,,269.33,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,269.33,
nitroglycerin 50 mg/250 mL-D5W PREMIX IV Sol [KHKS],6192256,CDM,636,RC,J2305,HCPCS,00338-1049-02,NDC,Outpatient,250,ML,81.14,,,,80,,64.91,percent of total billed charges,,,,85,68.97,percent of total billed charges,,,77.7,,63.04,percent of total billed charges,,,95,,77.08,percent of total billed charges,,,60,,48.68,percent of total billed charges,,48.68,77.08,
nitroglycerin 50 mg/250 mL-D5W PREMIX IV Sol [KHKS],6192256,CDM,636,RC,J2305,HCPCS,00338-1049-02,NDC,Inpatient,250,ML,81.14,,,,80,,64.91,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,63.04,percent of total billed charges,,,95,,77.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.08,
atenolol 25 mg Tab [KHKS],6192257,CDM,250,RC,51079-0759-20,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
atenolol 25 mg Tab [KHKS],6192257,CDM,250,RC,51079-0759-20,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
methylergonovine 0.2 mg/mL Inj Sol 1mL [KHKS],6192258,CDM,636,RC,J2210,HCPCS,51991-0144-17,NDC,Outpatient,1,ML,71.14,,,,80,,56.91,percent of total billed charges,,,,50,13.12,fee schedule,,,77.7,,55.27,percent of total billed charges,,,95,,67.58,percent of total billed charges,,,60,,42.68,percent of total billed charges,,13.12,67.58,
methylergonovine 0.2 mg/mL Inj Sol 1mL [KHKS],6192258,CDM,636,RC,J2210,HCPCS,51991-0144-17,NDC,Inpatient,1,ML,71.14,,,,80,,56.91,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,55.27,percent of total billed charges,,,95,,67.58,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,67.58,
finasteride 5 mg Tab [KHKS],6192259,CDM,250,RC,00904-6830-06,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
finasteride 5 mg Tab [KHKS],6192259,CDM,250,RC,00904-6830-06,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
buPROPion 150 mg/24 hours ER Tab [KHKS],6192260,CDM,250,RC,50268-0140-13,NDC,,,Outpatient,1,EA,23.29,,,,80,,18.63,percent of total billed charges,,,,85,19.8,percent of total billed charges,,,77.7,,18.1,percent of total billed charges,,,95,,22.13,percent of total billed charges,,,60,,13.97,percent of total billed charges,,13.97,22.13,
buPROPion 150 mg/24 hours ER Tab [KHKS],6192260,CDM,250,RC,50268-0140-13,NDC,,,Inpatient,1,EA,23.29,,,,80,,18.63,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,18.1,percent of total billed charges,,,95,,22.13,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,22.13,
succinylcholine 20 mg/mL Inj Sol 10 mL [KHKS],6192261,CDM,636,RC,J0330,HCPCS,43598-0666-25,NDC,Outpatient,10,ML,28.98,,,,80,,23.18,percent of total billed charges,,,,50,0.63,fee schedule,,,77.7,,22.52,percent of total billed charges,,,95,,27.53,percent of total billed charges,,,60,,17.39,percent of total billed charges,,0.63,27.53,
succinylcholine 20 mg/mL Inj Sol 10 mL [KHKS],6192261,CDM,636,RC,J0330,HCPCS,43598-0666-25,NDC,Inpatient,10,ML,28.98,,,,80,,23.18,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,22.52,percent of total billed charges,,,95,,27.53,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,27.53,
divalproex sodium 125 mg Oral EC Cap [KHKS],6192262,CDM,250,RC,55111-0532-01,NDC,,,Outpatient,1,EA,3.36,,,,80,,2.69,percent of total billed charges,,,,85,2.86,percent of total billed charges,,,77.7,,2.61,percent of total billed charges,,,95,,3.19,percent of total billed charges,,,60,,2.02,percent of total billed charges,,2.02,3.19,
divalproex sodium 125 mg Oral EC Cap [KHKS],6192262,CDM,250,RC,55111-0532-01,NDC,,,Inpatient,1,EA,3.36,,,,80,,2.69,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.61,percent of total billed charges,,,95,,3.19,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.19,
pregabalin 50 mg Oral Cap [KHKS],6192263,CDM,250,RC,60687-0484-01,NDC,,,Outpatient,1,EA,4.85,,,,80,,3.88,percent of total billed charges,,,,85,4.12,percent of total billed charges,,,77.7,,3.77,percent of total billed charges,,,95,,4.61,percent of total billed charges,,,60,,2.91,percent of total billed charges,,2.91,4.61,
pregabalin 50 mg Oral Cap [KHKS],6192263,CDM,250,RC,60687-0484-01,NDC,,,Inpatient,1,EA,4.85,,,,80,,3.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.77,percent of total billed charges,,,95,,4.61,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.61,
calcium-vitamin D 600 mg-10 mcg (400 intl units) Tab [KHKS],6192264,CDM,250,RC,77333-0115-10,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
calcium-vitamin D 600 mg-10 mcg (400 intl units) Tab [KHKS],6192264,CDM,250,RC,77333-0115-10,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
amoxicillin 400 mg/5 mL Oral Liq 50 mL [KHKS],6192265,CDM,250,RC,65862-0071-50,NDC,,,Outpatient,50,ML,14.55,,,,80,,11.64,percent of total billed charges,,,,85,12.37,percent of total billed charges,,,77.7,,11.31,percent of total billed charges,,,95,,13.82,percent of total billed charges,,,60,,8.73,percent of total billed charges,,8.73,13.82,
amoxicillin 400 mg/5 mL Oral Liq 50 mL [KHKS],6192265,CDM,250,RC,65862-0071-50,NDC,,,Inpatient,50,ML,14.55,,,,80,,11.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.31,percent of total billed charges,,,95,,13.82,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.82,
Dextrose 5% in Water IV Sol 100 mL [KHKS],6192266,CDM,636,RC,J7060,HCPCS,00990-7923-37,NDC,Outpatient,100,ML,7.56,,,,80,,6.05,percent of total billed charges,,,,50,1.12,fee schedule,,,77.7,,5.87,percent of total billed charges,,,95,,7.18,percent of total billed charges,,,60,,4.54,percent of total billed charges,,1.12,7.18,
Dextrose 5% in Water IV Sol 100 mL [KHKS],6192266,CDM,636,RC,J7060,HCPCS,00990-7923-37,NDC,Inpatient,100,ML,7.56,,,,80,,6.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.87,percent of total billed charges,,,95,,7.18,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.18,
EPINEPHrine 1 mg/mL Inj Sol 1 mL [KHKS],6192267,CDM,636,RC,J0171,HCPCS,42023-0159-25,NDC,Outpatient,1,ML,53.86,,,,80,,43.08,percent of total billed charges,,,,50,0.47,fee schedule,,,77.7,,41.85,percent of total billed charges,,,95,,51.16,percent of total billed charges,,,60,,32.31,percent of total billed charges,,0.47,51.16,
EPINEPHrine 1 mg/mL Inj Sol 1 mL [KHKS],6192267,CDM,636,RC,J0171,HCPCS,42023-0159-25,NDC,Inpatient,1,ML,53.86,,,,80,,43.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,41.85,percent of total billed charges,,,95,,51.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,51.16,
benazepril 10 mg Tab [KHKS],6192268,CDM,250,RC,65862-0116-01,NDC,,,Outpatient,1,EA,3.15,,,,80,,2.52,percent of total billed charges,,,,85,2.68,percent of total billed charges,,,77.7,,2.45,percent of total billed charges,,,95,,3,percent of total billed charges,,,60,,1.89,percent of total billed charges,,1.89,3,
benazepril 10 mg Tab [KHKS],6192268,CDM,250,RC,65862-0116-01,NDC,,,Inpatient,1,EA,3.15,,,,80,,2.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.45,percent of total billed charges,,,95,,3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3,
morphine 2 mg/mL PF IV Sol 1 mL [KHKS],6192269,CDM,636,RC,J2270,HCPCS,00409-1890-01,NDC,Outpatient,1,ML,7.67,,,,80,,6.13,percent of total billed charges,,,,50,2.15,fee schedule,,,77.7,,5.96,percent of total billed charges,,,95,,7.28,percent of total billed charges,,,60,,4.6,percent of total billed charges,,2.15,7.28,
morphine 2 mg/mL PF IV Sol 1 mL [KHKS],6192269,CDM,636,RC,J2270,HCPCS,00409-1890-01,NDC,Inpatient,1,ML,7.67,,,,80,,6.13,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.96,percent of total billed charges,,,95,,7.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.28,
hydrocortisone Top 1% Crm 15 gm [KHKS],6192270,CDM,250,RC,51672-2013-01,NDC,,,Outpatient,15,EA,13.5,,,,80,,10.8,percent of total billed charges,,,,85,11.48,percent of total billed charges,,,77.7,,10.49,percent of total billed charges,,,95,,12.83,percent of total billed charges,,,60,,8.1,percent of total billed charges,,8.1,12.83,
hydrocortisone Top 1% Crm 15 gm [KHKS],6192270,CDM,250,RC,51672-2013-01,NDC,,,Inpatient,15,EA,13.5,,,,80,,10.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.49,percent of total billed charges,,,95,,12.83,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,12.83,
furosemide 20 mg Tab [KHKS],6192271,CDM,250,RC,00054-8297-25,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
furosemide 20 mg Tab [KHKS],6192271,CDM,250,RC,00054-8297-25,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
erythromycin Ophth 0.5% Oint 1 gm [KHKS],6192273,CDM,250,RC,24208-0910-19,NDC,,,Outpatient,1,EA,37.24,,,,80,,29.8,percent of total billed charges,,,,85,31.65,percent of total billed charges,,,77.7,,28.94,percent of total billed charges,,,95,,35.38,percent of total billed charges,,,60,,22.35,percent of total billed charges,,22.35,35.38,
erythromycin Ophth 0.5% Oint 1 gm [KHKS],6192273,CDM,250,RC,24208-0910-19,NDC,,,Inpatient,1,EA,37.24,,,,80,,29.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,28.94,percent of total billed charges,,,95,,35.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,35.38,
guaiFENesin 100 mg/5 mL Oral Liq [KHKS],6192275,CDM,250,RC,00121-1744-05,NDC,,,Outpatient,5,ML,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
guaiFENesin 100 mg/5 mL Oral Liq [KHKS],6192275,CDM,250,RC,00121-1744-05,NDC,,,Inpatient,5,ML,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
NIFEdipine 30 mg ER Tab [KHKS],6192276,CDM,250,RC,50268-0597-15,NDC,,,Outpatient,1,EA,3.94,,,,80,,3.15,percent of total billed charges,,,,85,3.35,percent of total billed charges,,,77.7,,3.06,percent of total billed charges,,,95,,3.74,percent of total billed charges,,,60,,2.36,percent of total billed charges,,2.36,3.74,
NIFEdipine 30 mg ER Tab [KHKS],6192276,CDM,250,RC,50268-0597-15,NDC,,,Inpatient,1,EA,3.94,,,,80,,3.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.06,percent of total billed charges,,,95,,3.74,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.74,
EPINEPHrine 0.1 mg/mL Inj Sol 10 mL [KHKS],6192277,CDM,636,RC,J0171,HCPCS,76329-3316-01,NDC,Outpatient,10,ML,35.46,,,,80,,28.37,percent of total billed charges,,,,50,0.47,fee schedule,,,77.7,,27.55,percent of total billed charges,,,95,,33.69,percent of total billed charges,,,60,,21.28,percent of total billed charges,,0.47,33.69,
EPINEPHrine 0.1 mg/mL Inj Sol 10 mL [KHKS],6192277,CDM,636,RC,J0171,HCPCS,76329-3316-01,NDC,Inpatient,10,ML,35.46,,,,80,,28.37,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,27.55,percent of total billed charges,,,95,,33.69,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,33.69,
melatonin 3 mg Tab [KHKS],6192278,CDM,250,RC,57896-0864-06,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
melatonin 3 mg Tab [KHKS],6192278,CDM,250,RC,57896-0864-06,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
rivaroxaban 10 mg Tab [KHKS],6192279,CDM,250,RC,50458-0580-10,NDC,,,Outpatient,1,EA,62,,,,80,,49.6,percent of total billed charges,,,,85,52.7,percent of total billed charges,,,77.7,,48.17,percent of total billed charges,,,95,,58.9,percent of total billed charges,,,60,,37.2,percent of total billed charges,,37.2,58.9,
rivaroxaban 10 mg Tab [KHKS],6192279,CDM,250,RC,50458-0580-10,NDC,,,Inpatient,1,EA,62,,,,80,,49.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,48.17,percent of total billed charges,,,95,,58.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,58.9,
sodium hypochlorite Top 0.25% Sol [KHKS],6192280,CDM,250,RC,00436-0936-16,NDC,,,Outpatient,473,EA,41.58,,,,80,,33.26,percent of total billed charges,,,,85,35.34,percent of total billed charges,,,77.7,,32.31,percent of total billed charges,,,95,,39.5,percent of total billed charges,,,60,,24.95,percent of total billed charges,,24.95,39.5,
sodium hypochlorite Top 0.25% Sol [KHKS],6192280,CDM,250,RC,00436-0936-16,NDC,,,Inpatient,473,EA,41.58,,,,80,,33.26,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,32.31,percent of total billed charges,,,95,,39.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,39.5,
glucose 24 g/31 g Oral Gel [KHKS],6192281,CDM,250,RC,00187-0746-33,NDC,,,Outpatient,31,EA,13.43,,,,80,,10.74,percent of total billed charges,,,,85,11.42,percent of total billed charges,,,77.7,,10.44,percent of total billed charges,,,95,,12.76,percent of total billed charges,,,60,,8.06,percent of total billed charges,,8.06,12.76,
glucose 24 g/31 g Oral Gel [KHKS],6192281,CDM,250,RC,00187-0746-33,NDC,,,Inpatient,31,EA,13.43,,,,80,,10.74,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.44,percent of total billed charges,,,95,,12.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,12.76,
temazepam 15 mg Cap [KHKS],6192282,CDM,250,RC,00406-9961-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
temazepam 15 mg Cap [KHKS],6192282,CDM,250,RC,00406-9961-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
busPIRone 5 mg Tab [KHKS],6192283,CDM,250,RC,51079-0985-20,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
busPIRone 5 mg Tab [KHKS],6192283,CDM,250,RC,51079-0985-20,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
charcoal-sorbitol 25 g Oral Susp 120 mL [KHKS],6192284,CDM,250,RC,00574-0520-04,NDC,,,Outpatient,120,ML,50.1,,,,80,,40.08,percent of total billed charges,,,,85,42.59,percent of total billed charges,,,77.7,,38.93,percent of total billed charges,,,95,,47.6,percent of total billed charges,,,60,,30.06,percent of total billed charges,,30.06,47.6,
charcoal-sorbitol 25 g Oral Susp 120 mL [KHKS],6192284,CDM,250,RC,00574-0520-04,NDC,,,Inpatient,120,ML,50.1,,,,80,,40.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,38.93,percent of total billed charges,,,95,,47.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,47.6,
levofloxacin 750 mg/150 mL D5W PREMIX IV Sol [KHKS],6192285,CDM,636,RC,J1956,HCPCS,25021-0132-83,NDC,Outpatient,150,ML,39.6,,,,80,,31.68,percent of total billed charges,,,,50,0.73,fee schedule,,,77.7,,30.77,percent of total billed charges,,,95,,37.62,percent of total billed charges,,,60,,23.76,percent of total billed charges,,0.73,37.62,
levofloxacin 750 mg/150 mL D5W PREMIX IV Sol [KHKS],6192285,CDM,636,RC,J1956,HCPCS,25021-0132-83,NDC,Inpatient,150,ML,39.6,,,,80,,31.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,30.77,percent of total billed charges,,,95,,37.62,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,37.62,
sodium chloride nasal 0.65% Gel 14.1 gm [KHKS],6192286,CDM,250,RC,00225-0525-47,NDC,,,Outpatient,14.1,EA,9.54,,,,80,,7.63,percent of total billed charges,,,,85,8.11,percent of total billed charges,,,77.7,,7.41,percent of total billed charges,,,95,,9.06,percent of total billed charges,,,60,,5.72,percent of total billed charges,,5.72,9.06,
sodium chloride nasal 0.65% Gel 14.1 gm [KHKS],6192286,CDM,250,RC,00225-0525-47,NDC,,,Inpatient,14.1,EA,9.54,,,,80,,7.63,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.41,percent of total billed charges,,,95,,9.06,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.06,
sodium bicarbonate 650 mg Tab [KHKS],6192287,CDM,250,RC,77333-0831-10,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
sodium bicarbonate 650 mg Tab [KHKS],6192287,CDM,250,RC,77333-0831-10,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
traMADol 50 mg Tab [KHKS],6192288,CDM,250,RC,68084-0808-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
traMADol 50 mg Tab [KHKS],6192288,CDM,250,RC,68084-0808-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
acetaZOLAMIDE 250 mg Tab [KHKS],6192290,CDM,250,RC,00904-6663-61,NDC,,,Outpatient,1,EA,13,,,,80,,10.4,percent of total billed charges,,,,85,11.05,percent of total billed charges,,,77.7,,10.1,percent of total billed charges,,,95,,12.35,percent of total billed charges,,,60,,7.8,percent of total billed charges,,7.8,12.35,
acetaZOLAMIDE 250 mg Tab [KHKS],6192290,CDM,250,RC,00904-6663-61,NDC,,,Inpatient,1,EA,13,,,,80,,10.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.1,percent of total billed charges,,,95,,12.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,12.35,
silver sulfADIAZINE Top 1% Crm 400 gm [KHKS],6192291,CDM,250,RC,43598-0210-40,NDC,,,Outpatient,400,EA,190.77,,,,80,,152.62,percent of total billed charges,,,,85,162.15,percent of total billed charges,,,77.7,,148.23,percent of total billed charges,,,95,,181.23,percent of total billed charges,,,60,,114.46,percent of total billed charges,,114.46,181.23,
silver sulfADIAZINE Top 1% Crm 400 gm [KHKS],6192291,CDM,250,RC,43598-0210-40,NDC,,,Inpatient,400,EA,190.77,,,,80,,152.62,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,148.23,percent of total billed charges,,,95,,181.23,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,181.23,
pneumococcal 20-valent conjugate vaccine - Sus 0.5 mL [KHKS],6192292,CDM,636,RC,90677,CPT,00005-2000-10,NDC,Outpatient,0.5,ML,552.5,,,,80,,442,percent of total billed charges,,,,50,177.7,fee schedule,,,77.7,,429.29,percent of total billed charges,,,95,,524.88,percent of total billed charges,,,60,,331.5,percent of total billed charges,,331.5,524.88,
pneumococcal 20-valent conjugate vaccine - Sus 0.5 mL [KHKS],6192292,CDM,636,RC,90677,CPT,00005-2000-10,NDC,Inpatient,0.5,ML,552.5,,,,80,,442,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,429.29,percent of total billed charges,,,95,,524.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,524.88,
meropenem 1 g IV Inj Vial [KHKS],6192293,CDM,636,RC,J2185,HCPCS,55150-0208-30,NDC,Outpatient,1,EA,66,,,,80,,52.8,percent of total billed charges,,,,50,0.47,fee schedule,,,77.7,,51.28,percent of total billed charges,,,95,,62.7,percent of total billed charges,,,60,,39.6,percent of total billed charges,,0.47,62.7,
meropenem 1 g IV Inj Vial [KHKS],6192293,CDM,636,RC,J2185,HCPCS,55150-0208-30,NDC,Inpatient,1,EA,66,,,,80,,52.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,51.28,percent of total billed charges,,,95,,62.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,62.7,
ferrous sulfate 325 mg Tab [KHKS],6192294,CDM,250,RC,00904-7591-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
ferrous sulfate 325 mg Tab [KHKS],6192294,CDM,250,RC,00904-7591-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
sulfamethoxazole-trimethoprim 200 mg-40 mg/5 mL Oral Susp 473 mL [KHKS],6192295,CDM,250,RC,65862-0496-47,NDC,,,Outpatient,473,ML,398.49,,,,80,,318.79,percent of total billed charges,,,,85,338.72,percent of total billed charges,,,77.7,,309.63,percent of total billed charges,,,95,,378.57,percent of total billed charges,,,60,,239.09,percent of total billed charges,,239.09,378.57,
sulfamethoxazole-trimethoprim 200 mg-40 mg/5 mL Oral Susp 473 mL [KHKS],6192295,CDM,250,RC,65862-0496-47,NDC,,,Inpatient,473,ML,398.49,,,,80,,318.79,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,309.63,percent of total billed charges,,,95,,378.57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,378.57,
metoclopramide 10 mg Tab [KHKS],6192297,CDM,250,RC,51079-0888-20,NDC,,,Outpatient,1,EA,2.87,,,,80,,2.3,percent of total billed charges,,,,85,2.44,percent of total billed charges,,,77.7,,2.23,percent of total billed charges,,,95,,2.73,percent of total billed charges,,,60,,1.72,percent of total billed charges,,1.72,2.73,
metoclopramide 10 mg Tab [KHKS],6192297,CDM,250,RC,51079-0888-20,NDC,,,Inpatient,1,EA,2.87,,,,80,,2.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.23,percent of total billed charges,,,95,,2.73,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.73,
oxyCODONE 5 mg Tab [KHKS],6192298,CDM,250,RC,42858-0001-10,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
oxyCODONE 5 mg Tab [KHKS],6192298,CDM,250,RC,42858-0001-10,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
midazolam 1 mg/mL Inj Sol 2 mL [KHKS],6192299,CDM,636,RC,J2250,HCPCS,72611-0741-25,NDC,Outpatient,2,ML,2.5,,,,80,,2,percent of total billed charges,,,,50,0.11,fee schedule,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,0.11,2.38,
midazolam 1 mg/mL Inj Sol 2 mL [KHKS],6192299,CDM,636,RC,J2250,HCPCS,72611-0741-25,NDC,Inpatient,2,ML,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
lidocaine 2 g/500 mL (0.4%) D5W 500 mL Premix Sol [KHKS],6192300,CDM,636,RC,J2002,HCPCS,00338-0409-03,NDC,Outpatient,500,ML,24.47,,,,80,,19.58,percent of total billed charges,,,,85,20.8,percent of total billed charges,,,77.7,,19.02,percent of total billed charges,,,95,,23.25,percent of total billed charges,,,60,,14.68,percent of total billed charges,,14.68,23.25,
lidocaine 2 g/500 mL (0.4%) D5W 500 mL Premix Sol [KHKS],6192300,CDM,636,RC,J2002,HCPCS,00338-0409-03,NDC,Inpatient,500,ML,24.47,,,,80,,19.58,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.02,percent of total billed charges,,,95,,23.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,23.25,
OLANZapine 2.5 mg Tab [KHKS],6192301,CDM,250,RC,60505-3110-00,NDC,,,Outpatient,1,EA,33.59,,,,80,,26.87,percent of total billed charges,,,,85,28.55,percent of total billed charges,,,77.7,,26.1,percent of total billed charges,,,95,,31.91,percent of total billed charges,,,60,,20.16,percent of total billed charges,,20.16,31.91,
OLANZapine 2.5 mg Tab [KHKS],6192301,CDM,250,RC,60505-3110-00,NDC,,,Inpatient,1,EA,33.59,,,,80,,26.87,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,26.1,percent of total billed charges,,,95,,31.91,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,31.91,
sugammadex 100 mg/mL Sol 2 mL [KHKS],6192302,CDM,250,RC,00006-5423-12,NDC,,,Outpatient,2,ML,311.63,,,,80,,249.31,percent of total billed charges,,,,85,264.89,percent of total billed charges,,,77.7,,242.14,percent of total billed charges,,,95,,296.05,percent of total billed charges,,,60,,186.98,percent of total billed charges,,186.98,296.05,
sugammadex 100 mg/mL Sol 2 mL [KHKS],6192302,CDM,250,RC,00006-5423-12,NDC,,,Inpatient,2,ML,311.63,,,,80,,249.31,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,242.14,percent of total billed charges,,,95,,296.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,296.05,
sodium chloride bacteriostatic 0.9% Inj Sol 10 mL [KHKS],6192303,CDM,250,RC,63323-0924-10,NDC,,,Outpatient,10,ML,3.24,,,,80,,2.59,percent of total billed charges,,,,85,2.75,percent of total billed charges,,,77.7,,2.52,percent of total billed charges,,,95,,3.08,percent of total billed charges,,,60,,1.94,percent of total billed charges,,1.94,3.08,
sodium chloride bacteriostatic 0.9% Inj Sol 10 mL [KHKS],6192303,CDM,250,RC,63323-0924-10,NDC,,,Inpatient,10,ML,3.24,,,,80,,2.59,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.52,percent of total billed charges,,,95,,3.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.08,
azithromycin 200 mg/5 mL Oral Liq 15 mL [KHKS],6192304,CDM,250,RC,42806-0149-32,NDC,,,Outpatient,15,ML,104.64,,,,80,,83.71,percent of total billed charges,,,,85,88.94,percent of total billed charges,,,77.7,,81.31,percent of total billed charges,,,95,,99.41,percent of total billed charges,,,60,,62.78,percent of total billed charges,,62.78,99.41,
azithromycin 200 mg/5 mL Oral Liq 15 mL [KHKS],6192304,CDM,250,RC,42806-0149-32,NDC,,,Inpatient,15,ML,104.64,,,,80,,83.71,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,81.31,percent of total billed charges,,,95,,99.41,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,99.41,
cephalexin 500 mg Cap [KHKS],6192305,CDM,250,RC,60687-0163-01,NDC,,,Outpatient,1,EA,4.06,,,,80,,3.24,percent of total billed charges,,,,85,3.45,percent of total billed charges,,,77.7,,3.15,percent of total billed charges,,,95,,3.85,percent of total billed charges,,,60,,2.43,percent of total billed charges,,2.43,3.85,
cephalexin 500 mg Cap [KHKS],6192305,CDM,250,RC,60687-0163-01,NDC,,,Inpatient,1,EA,4.06,,,,80,,3.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.15,percent of total billed charges,,,95,,3.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.85,
glycopyrrolate 0.2 mg/mL Inj Sol 5 mL MDV [KHKS],6192306,CDM,636,RC,J1596,HCPCS,63323-0578-05,NDC,Outpatient,5,ML,107.64,,,,80,,86.11,percent of total billed charges,,,,85,91.49,percent of total billed charges,,,77.7,,83.64,percent of total billed charges,,,95,,102.26,percent of total billed charges,,,60,,64.58,percent of total billed charges,,64.58,102.26,
glycopyrrolate 0.2 mg/mL Inj Sol 5 mL MDV [KHKS],6192306,CDM,636,RC,J1596,HCPCS,63323-0578-05,NDC,Inpatient,5,ML,107.64,,,,80,,86.11,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,83.64,percent of total billed charges,,,95,,102.26,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,102.26,
EPINEPHrine 1 mg/mL Inj Sol 30 mL MDV [KHKS],6192307,CDM,636,RC,J0171,HCPCS,42023-0168-99,NDC,Outpatient,30,ML,556.27,,,,80,,445.01,percent of total billed charges,,,,50,0.47,fee schedule,,,77.7,,432.22,percent of total billed charges,,,95,,528.45,percent of total billed charges,,,60,,333.76,percent of total billed charges,,0.47,528.45,
EPINEPHrine 1 mg/mL Inj Sol 30 mL MDV [KHKS],6192307,CDM,636,RC,J0171,HCPCS,42023-0168-99,NDC,Inpatient,30,ML,556.27,,,,80,,445.01,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,432.22,percent of total billed charges,,,95,,528.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,528.45,
"nystatin Top 100,000 units/g Crm 30 gm [KHKS]",6192308,CDM,250,RC,45802-0059-11,NDC,,,Outpatient,30,EA,78.75,,,,80,,63,percent of total billed charges,,,,85,66.94,percent of total billed charges,,,77.7,,61.19,percent of total billed charges,,,95,,74.81,percent of total billed charges,,,60,,47.25,percent of total billed charges,,47.25,74.81,
"nystatin Top 100,000 units/g Crm 30 gm [KHKS]",6192308,CDM,250,RC,45802-0059-11,NDC,,,Inpatient,30,EA,78.75,,,,80,,63,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,61.19,percent of total billed charges,,,95,,74.81,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,74.81,
diphenhydrAMINE-zinc acetate Top 2%-0.1% Crm 30 gm[KHKS],6192309,CDM,250,RC,00501-3201-01,NDC,,,Outpatient,30,EA,12.06,,,,80,,9.65,percent of total billed charges,,,,85,10.25,percent of total billed charges,,,77.7,,9.37,percent of total billed charges,,,95,,11.46,percent of total billed charges,,,60,,7.24,percent of total billed charges,,7.24,11.46,
diphenhydrAMINE-zinc acetate Top 2%-0.1% Crm 30 gm[KHKS],6192309,CDM,250,RC,00501-3201-01,NDC,,,Inpatient,30,EA,12.06,,,,80,,9.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.37,percent of total billed charges,,,95,,11.46,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.46,
phenol Top 1.4% Spry 177 mL [KHKS],6192310,CDM,250,RC,78112-0011-03,NDC,,,Outpatient,177,EA,21.74,,,,80,,17.39,percent of total billed charges,,,,85,18.48,percent of total billed charges,,,77.7,,16.89,percent of total billed charges,,,95,,20.65,percent of total billed charges,,,60,,13.04,percent of total billed charges,,13.04,20.65,
phenol Top 1.4% Spry 177 mL [KHKS],6192310,CDM,250,RC,78112-0011-03,NDC,,,Inpatient,177,EA,21.74,,,,80,,17.39,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,16.89,percent of total billed charges,,,95,,20.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,20.65,
dihydroergotamine 1 mg/mL Inj Sol [KHKS],6192311,CDM,636,RC,J1110,HCPCS,00574-0850-05,NDC,Outpatient,1,ML,354.65,,,,80,,283.72,percent of total billed charges,,,,50,36.8,fee schedule,,,77.7,,275.56,percent of total billed charges,,,95,,336.91,percent of total billed charges,,,60,,212.79,percent of total billed charges,,36.8,336.91,
dihydroergotamine 1 mg/mL Inj Sol [KHKS],6192311,CDM,636,RC,J1110,HCPCS,00574-0850-05,NDC,Inpatient,1,ML,354.65,,,,80,,283.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,275.56,percent of total billed charges,,,95,,336.91,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,336.91,
escitalopram 10 mg Tab [KHKS],6192312,CDM,250,RC,00904-6426-61,NDC,,,Outpatient,1,EA,13.14,,,,80,,10.51,percent of total billed charges,,,,85,11.17,percent of total billed charges,,,77.7,,10.21,percent of total billed charges,,,95,,12.48,percent of total billed charges,,,60,,7.89,percent of total billed charges,,7.89,12.48,
escitalopram 10 mg Tab [KHKS],6192312,CDM,250,RC,00904-6426-61,NDC,,,Inpatient,1,EA,13.14,,,,80,,10.51,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.21,percent of total billed charges,,,95,,12.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,12.48,
verapamil 5.  Soln,6192313,CDM,250,RC,72485-0108-05,NDC,,,Outpatient,2,ML,60.96,,,,80,,48.77,percent of total billed charges,,,,85,51.82,percent of total billed charges,,,77.7,,47.37,percent of total billed charges,,,95,,57.91,percent of total billed charges,,,60,,36.58,percent of total billed charges,,36.58,57.91,
verapamil 5.  Soln,6192313,CDM,250,RC,72485-0108-05,NDC,,,Inpatient,2,ML,60.96,,,,80,,48.77,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,47.37,percent of total billed charges,,,95,,57.91,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,57.91,
levothyroxine 50 mcg (0.05 mg) Tab [KHKS],6192314,CDM,250,RC,51079-0440-20,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
levothyroxine 50 mcg (0.05 mg) Tab [KHKS],6192314,CDM,250,RC,51079-0440-20,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
acyclovir 50 mg/mL IV Sol 10 mL [KHKS],6192315,CDM,636,RC,J0133,HCPCS,63323-0325-10,NDC,Outpatient,10,ML,67.68,,,,80,,54.14,percent of total billed charges,,,,50,0.03,fee schedule,,,77.7,,52.59,percent of total billed charges,,,95,,64.3,percent of total billed charges,,,60,,40.61,percent of total billed charges,,0.03,64.3,
acyclovir 50 mg/mL IV Sol 10 mL [KHKS],6192315,CDM,636,RC,J0133,HCPCS,63323-0325-10,NDC,Inpatient,10,ML,67.68,,,,80,,54.14,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,52.59,percent of total billed charges,,,95,,64.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,64.3,
meclizine 25 mg Tab [KHKS],6192316,CDM,250,RC,00904-6517-61,NDC,,,Outpatient,1,EA,2.61,,,,80,,2.09,percent of total billed charges,,,,85,2.22,percent of total billed charges,,,77.7,,2.03,percent of total billed charges,,,95,,2.48,percent of total billed charges,,,60,,1.56,percent of total billed charges,,1.56,2.48,
meclizine 25 mg Tab [KHKS],6192316,CDM,250,RC,00904-6517-61,NDC,,,Inpatient,1,EA,2.61,,,,80,,2.09,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.03,percent of total billed charges,,,95,,2.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.48,
EPINEPHrine 0.15 mg Inj kit [KHKS],6192317,CDM,636,RC,J0171,HCPCS,49502-0101-02,NDC,Outpatient,1,EA,421.88,,,,80,,337.5,percent of total billed charges,,,,50,0.47,fee schedule,,,77.7,,327.8,percent of total billed charges,,,95,,400.78,percent of total billed charges,,,60,,253.13,percent of total billed charges,,0.47,400.78,
EPINEPHrine 0.15 mg Inj kit [KHKS],6192317,CDM,636,RC,J0171,HCPCS,49502-0101-02,NDC,Inpatient,1,EA,421.88,,,,80,,337.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,327.8,percent of total billed charges,,,95,,400.78,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,400.78,
Dextrose 5% with 0.3% NaCl IV Sol 500 mL [KHKS],6192318,CDM,250,RC,00990-7925-03,NDC,,,Outpatient,500,ML,32.04,,,,80,,25.63,percent of total billed charges,,,,85,27.23,percent of total billed charges,,,77.7,,24.89,percent of total billed charges,,,95,,30.43,percent of total billed charges,,,60,,19.22,percent of total billed charges,,19.22,30.43,
Dextrose 5% with 0.3% NaCl IV Sol 500 mL [KHKS],6192318,CDM,250,RC,00990-7925-03,NDC,,,Inpatient,500,ML,32.04,,,,80,,25.63,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,24.89,percent of total billed charges,,,95,,30.43,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,30.43,
carBAMazepine 200 mg Tab [KHKS],6192319,CDM,250,RC,51672-4005-01,NDC,,,Outpatient,1,EA,4.8,,,,80,,3.84,percent of total billed charges,,,,85,4.08,percent of total billed charges,,,77.7,,3.73,percent of total billed charges,,,95,,4.56,percent of total billed charges,,,60,,2.88,percent of total billed charges,,2.88,4.56,
carBAMazepine 200 mg Tab [KHKS],6192319,CDM,250,RC,51672-4005-01,NDC,,,Inpatient,1,EA,4.8,,,,80,,3.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.73,percent of total billed charges,,,95,,4.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.56,
cyanocobalamin 1000 mcg/mL Inj Sol 1 mL [KHKS],6192320,CDM,636,RC,J3420,HCPCS,63323-0044-01,NDC,Outpatient,1,ML,24.88,,,,80,,19.9,percent of total billed charges,,,,50,1.32,fee schedule,,,77.7,,19.33,percent of total billed charges,,,95,,23.63,percent of total billed charges,,,60,,14.93,percent of total billed charges,,1.32,23.63,
cyanocobalamin 1000 mcg/mL Inj Sol 1 mL [KHKS],6192320,CDM,636,RC,J3420,HCPCS,63323-0044-01,NDC,Inpatient,1,ML,24.88,,,,80,,19.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.33,percent of total billed charges,,,95,,23.63,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,23.63,
triamcinolone acetonide 40 mg/mL Inj Susp 5 mL [KHKS],6192322,CDM,636,RC,J3301,HCPCS,70121-1652-01,NDC,Outpatient,5,ML,156.06,,,,80,,124.85,percent of total billed charges,,,,50,0.68,fee schedule,,,77.7,,121.26,percent of total billed charges,,,95,,148.26,percent of total billed charges,,,60,,93.64,percent of total billed charges,,0.68,148.26,
triamcinolone acetonide 40 mg/mL Inj Susp 5 mL [KHKS],6192322,CDM,636,RC,J3301,HCPCS,70121-1652-01,NDC,Inpatient,5,ML,156.06,,,,80,,124.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,121.26,percent of total billed charges,,,95,,148.26,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,148.26,
nitrofurantoin macrocrystals 50 mg Cap [KHKS],6192323,CDM,250,RC,68084-0077-01,NDC,,,Outpatient,1,EA,13.25,,,,80,,10.6,percent of total billed charges,,,,85,11.26,percent of total billed charges,,,77.7,,10.3,percent of total billed charges,,,95,,12.59,percent of total billed charges,,,60,,7.95,percent of total billed charges,,7.95,12.59,
nitrofurantoin macrocrystals 50 mg Cap [KHKS],6192323,CDM,250,RC,68084-0077-01,NDC,,,Inpatient,1,EA,13.25,,,,80,,10.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.3,percent of total billed charges,,,95,,12.59,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,12.59,
piperacillin-tazobactam 4.5 g IV Inj Vial [KHKS],6192324,CDM,636,RC,J2543,HCPCS,55150-0121-50,NDC,Outpatient,1,EA,82.65,,,,80,,66.12,percent of total billed charges,,,,50,1.15,fee schedule,,,77.7,,64.22,percent of total billed charges,,,95,,78.52,percent of total billed charges,,,60,,49.59,percent of total billed charges,,1.15,78.52,
piperacillin-tazobactam 4.5 g IV Inj Vial [KHKS],6192324,CDM,636,RC,J2543,HCPCS,55150-0121-50,NDC,Inpatient,1,EA,82.65,,,,80,,66.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,64.22,percent of total billed charges,,,95,,78.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,78.52,
aspirin 81 mg Oral EC Tab [KHKS],6192325,CDM,250,RC,70677-0132-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
aspirin 81 mg Oral EC Tab [KHKS],6192325,CDM,250,RC,70677-0132-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
ondansetron ODT 4 mg Tab [KHKS],6192326,CDM,250,RC,16714-0200-30,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
ondansetron ODT 4 mg Tab [KHKS],6192326,CDM,250,RC,16714-0200-30,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
azithromycin 250 mg Tab [KHKS],6192328,CDM,250,RC,50111-0787-10,NDC,,,Outpatient,1,EA,23.35,,,,80,,18.68,percent of total billed charges,,,,85,19.85,percent of total billed charges,,,77.7,,18.14,percent of total billed charges,,,95,,22.18,percent of total billed charges,,,60,,14.01,percent of total billed charges,,14.01,22.18,
azithromycin 250 mg Tab [KHKS],6192328,CDM,250,RC,50111-0787-10,NDC,,,Inpatient,1,EA,23.35,,,,80,,18.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,18.14,percent of total billed charges,,,95,,22.18,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,22.18,
Dextrose 5% with 0.225% NaCl IV Sol 500 mL [KHKS],6192329,CDM,250,RC,00990-7924-03,NDC,,,Outpatient,500,ML,16.53,,,,80,,13.22,percent of total billed charges,,,,85,14.05,percent of total billed charges,,,77.7,,12.84,percent of total billed charges,,,95,,15.7,percent of total billed charges,,,60,,9.92,percent of total billed charges,,9.92,15.7,
Dextrose 5% with 0.225% NaCl IV Sol 500 mL [KHKS],6192329,CDM,250,RC,00990-7924-03,NDC,,,Inpatient,500,ML,16.53,,,,80,,13.22,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.84,percent of total billed charges,,,95,,15.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.7,
orphenadrine 30 mg/mL Inj Sol 2 mL [KHKS],6192330,CDM,636,RC,J2360,HCPCS,17478-0538-02,NDC,Outpatient,2,ML,66.61,,,,80,,53.29,percent of total billed charges,,,,50,3.46,fee schedule,,,77.7,,51.76,percent of total billed charges,,,95,,63.28,percent of total billed charges,,,60,,39.97,percent of total billed charges,,3.46,63.28,
orphenadrine 30 mg/mL Inj Sol 2 mL [KHKS],6192330,CDM,636,RC,J2360,HCPCS,17478-0538-02,NDC,Inpatient,2,ML,66.61,,,,80,,53.29,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,51.76,percent of total billed charges,,,95,,63.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,63.28,
clindamycin 150 mg Cap [KHKS],6192331,CDM,250,RC,00904-5959-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
clindamycin 150 mg Cap [KHKS],6192331,CDM,250,RC,00904-5959-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
sterile water IRRIG Sol 500 mL [KHKS],6192333,CDM,250,RC,00990-6139-03,NDC,,,Outpatient,500,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,85,16.07,percent of total billed charges,,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,60,,11.34,percent of total billed charges,,11.34,17.96,
sterile water IRRIG Sol 500 mL [KHKS],6192333,CDM,250,RC,00990-6139-03,NDC,,,Inpatient,500,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.96,
piperacillin-tazobactam 3.375 g IV Inj Vial [KHKS],6192334,CDM,636,RC,J2543,HCPCS,55150-0120-30,NDC,Outpatient,1,EA,65.27,,,,80,,52.21,percent of total billed charges,,,,50,1.15,fee schedule,,,77.7,,50.71,percent of total billed charges,,,95,,62,percent of total billed charges,,,60,,39.16,percent of total billed charges,,1.15,62,
piperacillin-tazobactam 3.375 g IV Inj Vial [KHKS],6192334,CDM,636,RC,J2543,HCPCS,55150-0120-30,NDC,Inpatient,1,EA,65.27,,,,80,,52.21,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,50.71,percent of total billed charges,,,95,,62,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,62,
cholecalciferol 25 mcg (1000 intl units) Tab UD [KHKS],6192335,CDM,250,RC,80681-0168-00,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
cholecalciferol 25 mcg (1000 intl units) Tab UD [KHKS],6192335,CDM,250,RC,80681-0168-00,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
enoxaparin 30 mg/0.3 mL Sol Syringe [KHKS],6192336,CDM,636,RC,J1650,HCPCS,63323-0559-65,NDC,Outpatient,0.3,ML,10.84,,,,80,,8.67,percent of total billed charges,,,,50,0.52,fee schedule,,,77.7,,8.42,percent of total billed charges,,,95,,10.29,percent of total billed charges,,,60,,6.5,percent of total billed charges,,0.52,10.29,
enoxaparin 30 mg/0.3 mL Sol Syringe [KHKS],6192336,CDM,636,RC,J1650,HCPCS,63323-0559-65,NDC,Inpatient,0.3,ML,10.84,,,,80,,8.67,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.42,percent of total billed charges,,,95,,10.29,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.29,
polyethylene glycol 3350 Oral Pwdr for Recon 238 gm [KHKS],6192337,CDM,250,RC,49348-0143-70,NDC,,,Outpatient,238,EA,29.07,,,,80,,23.26,percent of total billed charges,,,,85,24.71,percent of total billed charges,,,77.7,,22.59,percent of total billed charges,,,95,,27.62,percent of total billed charges,,,60,,17.44,percent of total billed charges,,17.44,27.62,
polyethylene glycol 3350 Oral Pwdr for Recon 238 gm [KHKS],6192337,CDM,250,RC,49348-0143-70,NDC,,,Inpatient,238,EA,29.07,,,,80,,23.26,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,22.59,percent of total billed charges,,,95,,27.62,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,27.62,
ipratropium 0.5 mg/2.5 mL (0.02%) INH Sol 2.5 mL [KHKS],6192338,CDM,250,RC,76204-0100-25,NDC,,,Outpatient,2.5,ML,5.28,,,,80,,4.22,percent of total billed charges,,,,85,4.49,percent of total billed charges,,,77.7,,4.1,percent of total billed charges,,,95,,5.02,percent of total billed charges,,,60,,3.17,percent of total billed charges,,3.17,5.02,
ipratropium 0.5 mg/2.5 mL (0.02%) INH Sol 2.5 mL [KHKS],6192338,CDM,250,RC,76204-0100-25,NDC,,,Inpatient,2.5,ML,5.28,,,,80,,4.22,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.1,percent of total billed charges,,,95,,5.02,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.02,
menthol-zinc oxide topical 0.44%-20.6% Oin 71 gm [KHKS],6192340,CDM,250,RC,00799-0001-03,NDC,,,Outpatient,71,EA,21,,,,80,,16.8,percent of total billed charges,,,,85,17.85,percent of total billed charges,,,77.7,,16.32,percent of total billed charges,,,95,,19.95,percent of total billed charges,,,60,,12.6,percent of total billed charges,,12.6,19.95,
menthol-zinc oxide topical 0.44%-20.6% Oin 71 gm [KHKS],6192340,CDM,250,RC,00799-0001-03,NDC,,,Inpatient,71,EA,21,,,,80,,16.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,16.32,percent of total billed charges,,,95,,19.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,19.95,
bacitracin topical zinc 500 units/g Oint UD [KHKS],6192341,CDM,250,RC,57896-0111-14,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
bacitracin topical zinc 500 units/g Oint UD [KHKS],6192341,CDM,250,RC,57896-0111-14,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
Dextrose 5% with NS and KCl 20 mEq/l IV PREMIX Sol 1000 mL [KHKS],6192342,CDM,636,RC,J3480,HCPCS,00990-7107-09,NDC,Outpatient,1000,ML,25.6,,,,80,,20.48,percent of total billed charges,,,,50,0.09,fee schedule,,,77.7,,19.89,percent of total billed charges,,,95,,24.32,percent of total billed charges,,,60,,15.36,percent of total billed charges,,0.09,24.32,
Dextrose 5% with NS and KCl 20 mEq/l IV PREMIX Sol 1000 mL [KHKS],6192342,CDM,636,RC,J3480,HCPCS,00990-7107-09,NDC,Inpatient,1000,ML,25.6,,,,80,,20.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.89,percent of total billed charges,,,95,,24.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,24.32,
metoclopramide 5 mg/mL Inj Sol 2 mL [KHKS],6192343,CDM,636,RC,J2765,HCPCS,00409-3414-01,NDC,Outpatient,2,ML,4.26,,,,80,,3.41,percent of total billed charges,,,,50,0.71,fee schedule,,,77.7,,3.31,percent of total billed charges,,,95,,4.05,percent of total billed charges,,,60,,2.56,percent of total billed charges,,0.71,4.05,
metoclopramide 5 mg/mL Inj Sol 2 mL [KHKS],6192343,CDM,636,RC,J2765,HCPCS,00409-3414-01,NDC,Inpatient,2,ML,4.26,,,,80,,3.41,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.31,percent of total billed charges,,,95,,4.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.05,
sodium chloride 0.9% Inj Sol 10 mL Vial [KHKS],6192344,CDM,250,RC,00409-4888-10,NDC,,,Outpatient,10,ML,3.33,,,,80,,2.66,percent of total billed charges,,,,85,2.83,percent of total billed charges,,,77.7,,2.58,percent of total billed charges,,,95,,3.16,percent of total billed charges,,,60,,2,percent of total billed charges,,2,3.16,
sodium chloride 0.9% Inj Sol 10 mL Vial [KHKS],6192344,CDM,250,RC,00409-4888-10,NDC,,,Inpatient,10,ML,3.33,,,,80,,2.66,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.58,percent of total billed charges,,,95,,3.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.16,
spironolactone 25 mg Tab [KHKS],6192345,CDM,250,RC,63739-0544-10,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
spironolactone 25 mg Tab [KHKS],6192345,CDM,250,RC,63739-0544-10,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
rifAXIMin 550 mg Tab UD [KHKS],6192346,CDM,250,RC,65649-0303-03,NDC,,,Outpatient,1,EA,178.52,,,,80,,142.82,percent of total billed charges,,,,85,151.74,percent of total billed charges,,,77.7,,138.71,percent of total billed charges,,,95,,169.59,percent of total billed charges,,,60,,107.11,percent of total billed charges,,107.11,169.59,
rifAXIMin 550 mg Tab UD [KHKS],6192346,CDM,250,RC,65649-0303-03,NDC,,,Inpatient,1,EA,178.52,,,,80,,142.82,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,138.71,percent of total billed charges,,,95,,169.59,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,169.59,
diphenhydrAMINE 50 mg/mL Inj Sol [KHKS],6192347,CDM,636,RC,J1200,HCPCS,63323-0664-01,NDC,Outpatient,1,ML,9.9,,,,80,,7.92,percent of total billed charges,,,,50,0.75,fee schedule,,,77.7,,7.69,percent of total billed charges,,,95,,9.41,percent of total billed charges,,,60,,5.94,percent of total billed charges,,0.75,9.41,
diphenhydrAMINE 50 mg/mL Inj Sol [KHKS],6192347,CDM,636,RC,J1200,HCPCS,63323-0664-01,NDC,Inpatient,1,ML,9.9,,,,80,,7.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.69,percent of total billed charges,,,95,,9.41,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.41,
Dextrose 5% in Water IV Sol 1000 mL [KHKS],6192348,CDM,636,RC,J7060,HCPCS,00990-7922-09,NDC,Outpatient,1000,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,50,1.12,fee schedule,,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,60,,11.34,percent of total billed charges,,1.12,17.96,
Dextrose 5% in Water IV Sol 1000 mL [KHKS],6192348,CDM,636,RC,J7060,HCPCS,00990-7922-09,NDC,Inpatient,1000,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.96,
abatacept 250 mg IV Inj [KHKS],6192349,CDM,636,RC,J0129,HCPCS,00003-2187-13,NDC,Outpatient,1,EA,2890.42,,,,80,,2312.34,percent of total billed charges,,,,50,26.76,fee schedule,,,77.7,,2245.86,percent of total billed charges,,,95,,2745.9,percent of total billed charges,,,60,,1734.25,percent of total billed charges,,26.76,2745.9,
abatacept 250 mg IV Inj [KHKS],6192349,CDM,636,RC,J0129,HCPCS,00003-2187-13,NDC,Inpatient,1,EA,2890.42,,,,80,,2312.34,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2245.86,percent of total billed charges,,,95,,2745.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2745.9,
EPINEPHrine 0.3 mg Inj kit [KHKS],6192350,CDM,636,RC,J0171,HCPCS,49502-0102-02,NDC,Outpatient,1,EA,421.88,,,,80,,337.5,percent of total billed charges,,,,50,0.47,fee schedule,,,77.7,,327.8,percent of total billed charges,,,95,,400.78,percent of total billed charges,,,60,,253.13,percent of total billed charges,,0.47,400.78,
EPINEPHrine 0.3 mg Inj kit [KHKS],6192350,CDM,636,RC,J0171,HCPCS,49502-0102-02,NDC,Inpatient,1,EA,421.88,,,,80,,337.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,327.8,percent of total billed charges,,,95,,400.78,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,400.78,
cefuroxime 250 mg Tab [KHKS],6192351,CDM,250,RC,16714-0400-02,NDC,,,Outpatient,1,EA,13.48,,,,80,,10.79,percent of total billed charges,,,,85,11.46,percent of total billed charges,,,77.7,,10.48,percent of total billed charges,,,95,,12.81,percent of total billed charges,,,60,,8.09,percent of total billed charges,,8.09,12.81,
cefuroxime 250 mg Tab [KHKS],6192351,CDM,250,RC,16714-0400-02,NDC,,,Inpatient,1,EA,13.48,,,,80,,10.79,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.48,percent of total billed charges,,,95,,12.81,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,12.81,
ALPRAZolam 0.25 mg Tab [KHKS],6192352,CDM,250,RC,00781-1061-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
ALPRAZolam 0.25 mg Tab [KHKS],6192352,CDM,250,RC,00781-1061-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
magnesium hydroxide 8% Oral Susp 30 mL [KHKS],6192353,CDM,250,RC,00121-0431-30,NDC,,,Outpatient,30,ML,7.02,,,,80,,5.62,percent of total billed charges,,,,85,5.97,percent of total billed charges,,,77.7,,5.46,percent of total billed charges,,,95,,6.67,percent of total billed charges,,,60,,4.21,percent of total billed charges,,4.21,6.67,
magnesium hydroxide 8% Oral Susp 30 mL [KHKS],6192353,CDM,250,RC,00121-0431-30,NDC,,,Inpatient,30,ML,7.02,,,,80,,5.62,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.46,percent of total billed charges,,,95,,6.67,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.67,
acetaminophen-HYDROcodone 325 mg-5 mg Tab [KHKS],6192354,CDM,250,RC,50268-0401-15,NDC,,,Outpatient,1,EA,2.99,,,,80,,2.39,percent of total billed charges,,,,85,2.54,percent of total billed charges,,,77.7,,2.32,percent of total billed charges,,,95,,2.84,percent of total billed charges,,,60,,1.79,percent of total billed charges,,1.79,2.84,
acetaminophen-HYDROcodone 325 mg-5 mg Tab [KHKS],6192354,CDM,250,RC,50268-0401-15,NDC,,,Inpatient,1,EA,2.99,,,,80,,2.39,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.32,percent of total billed charges,,,95,,2.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.84,
cefepime 2 g Inj [KHKS],6192355,CDM,636,RC,J0692,HCPCS,60505-6145-04,NDC,Outpatient,1,EA,121.07,,,,80,,96.85,percent of total billed charges,,,,50,0.97,fee schedule,,,77.7,,94.07,percent of total billed charges,,,95,,115.01,percent of total billed charges,,,60,,72.64,percent of total billed charges,,0.97,115.01,
cefepime 2 g Inj [KHKS],6192355,CDM,636,RC,J0692,HCPCS,60505-6145-04,NDC,Inpatient,1,EA,121.07,,,,80,,96.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,94.07,percent of total billed charges,,,95,,115.01,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,115.01,
aminophylline 25 mg/mL IV Sol 10 mL [KHKS],6192356,CDM,636,RC,J0280,HCPCS,00409-5921-01,NDC,Outpatient,10,ML,49.5,,,,80,,39.6,percent of total billed charges,,,,50,8.42,fee schedule,,,77.7,,38.46,percent of total billed charges,,,95,,47.03,percent of total billed charges,,,60,,29.7,percent of total billed charges,,8.42,47.03,
aminophylline 25 mg/mL IV Sol 10 mL [KHKS],6192356,CDM,636,RC,J0280,HCPCS,00409-5921-01,NDC,Inpatient,10,ML,49.5,,,,80,,39.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,38.46,percent of total billed charges,,,95,,47.03,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,47.03,
rocuronium 10 mg/mL IV Sol 5 mL [KHKS],6192357,CDM,250,RC,39822-4200-02,NDC,,,Outpatient,5,ML,16.88,,,,80,,13.5,percent of total billed charges,,,,85,14.35,percent of total billed charges,,,77.7,,13.11,percent of total billed charges,,,95,,16.03,percent of total billed charges,,,60,,10.13,percent of total billed charges,,10.13,16.03,
rocuronium 10 mg/mL IV Sol 5 mL [KHKS],6192357,CDM,250,RC,39822-4200-02,NDC,,,Inpatient,5,ML,16.88,,,,80,,13.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,13.11,percent of total billed charges,,,95,,16.03,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,16.03,
sterile water bacteriostatic Inj Sol 30 mL [KHKS],6192358,CDM,250,RC,00409-3977-03,NDC,,,Outpatient,30,ML,5.9,,,,80,,4.72,percent of total billed charges,,,,85,5.02,percent of total billed charges,,,77.7,,4.59,percent of total billed charges,,,95,,5.61,percent of total billed charges,,,60,,3.54,percent of total billed charges,,3.54,5.61,
sterile water bacteriostatic Inj Sol 30 mL [KHKS],6192358,CDM,250,RC,00409-3977-03,NDC,,,Inpatient,30,ML,5.9,,,,80,,4.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.59,percent of total billed charges,,,95,,5.61,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.61,
ursodiol 300 mg Cap [KHKS],6192359,CDM,250,RC,00904-6221-06,NDC,,,Outpatient,1,EA,26.95,,,,80,,21.56,percent of total billed charges,,,,85,22.91,percent of total billed charges,,,77.7,,20.94,percent of total billed charges,,,95,,25.6,percent of total billed charges,,,60,,16.17,percent of total billed charges,,16.17,25.6,
ursodiol 300 mg Cap [KHKS],6192359,CDM,250,RC,00904-6221-06,NDC,,,Inpatient,1,EA,26.95,,,,80,,21.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,20.94,percent of total billed charges,,,95,,25.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,25.6,
zinc sulfate 220 mg Cap [KHKS],6192360,CDM,250,RC,77333-0983-10,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
zinc sulfate 220 mg Cap [KHKS],6192360,CDM,250,RC,77333-0983-10,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
calcium gluconate 100 mg/mL Inj Sol 10 mL [KHKS],6192361,CDM,636,RC,J0612,HCPCS,63323-0360-19,NDC,Outpatient,10,ML,36.07,,,,80,,28.86,percent of total billed charges,,,,50,0.03,fee schedule,,,77.7,,28.03,percent of total billed charges,,,95,,34.27,percent of total billed charges,,,60,,21.64,percent of total billed charges,,0.03,34.27,
calcium gluconate 100 mg/mL Inj Sol 10 mL [KHKS],6192361,CDM,636,RC,J0612,HCPCS,63323-0360-19,NDC,Inpatient,10,ML,36.07,,,,80,,28.86,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,28.03,percent of total billed charges,,,95,,34.27,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,34.27,
"ergocalciferol 1.25 mg (50,000 intl units) Cap [KHKS]",6192362,CDM,250,RC,64380-0737-06,NDC,,,Outpatient,1,EA,5.92,,,,80,,4.73,percent of total billed charges,,,,85,5.03,percent of total billed charges,,,77.7,,4.6,percent of total billed charges,,,95,,5.62,percent of total billed charges,,,60,,3.55,percent of total billed charges,,3.55,5.62,
"ergocalciferol 1.25 mg (50,000 intl units) Cap [KHKS]",6192362,CDM,250,RC,64380-0737-06,NDC,,,Inpatient,1,EA,5.92,,,,80,,4.73,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.6,percent of total billed charges,,,95,,5.62,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.62,
amoxicillin-clavulanate 400 mg-57 mg/5 mL Oral Liq 100 mL [KHKS],6192363,CDM,250,RC,16714-0293-03,NDC,,,Outpatient,100,ML,210.15,,,,80,,168.12,percent of total billed charges,,,,85,178.63,percent of total billed charges,,,77.7,,163.29,percent of total billed charges,,,95,,199.64,percent of total billed charges,,,60,,126.09,percent of total billed charges,,126.09,199.64,
amoxicillin-clavulanate 400 mg-57 mg/5 mL Oral Liq 100 mL [KHKS],6192363,CDM,250,RC,16714-0293-03,NDC,,,Inpatient,100,ML,210.15,,,,80,,168.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,163.29,percent of total billed charges,,,95,,199.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,199.64,
methylPREDNISolone acetate 80 mg/mL Inj Susp [KHKS],6192364,CDM,636,RC,J1010,HCPCS,70121-1552-05,NDC,Outpatient,1,ML,58.75,,,,80,,47,percent of total billed charges,,,,85,49.94,percent of total billed charges,,,77.7,,45.65,percent of total billed charges,,,95,,55.81,percent of total billed charges,,,60,,35.25,percent of total billed charges,,35.25,55.81,
methylPREDNISolone acetate 80 mg/mL Inj Susp [KHKS],6192364,CDM,636,RC,J1010,HCPCS,70121-1552-05,NDC,Inpatient,1,ML,58.75,,,,80,,47,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,45.65,percent of total billed charges,,,95,,55.81,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,55.81,
oxymetazoline Nasal 0.05% Spry 15 mL [KHKS],6192366,CDM,250,RC,11523-1159-01,NDC,,,Outpatient,15,EA,23.76,,,,80,,19.01,percent of total billed charges,,,,85,20.2,percent of total billed charges,,,77.7,,18.46,percent of total billed charges,,,95,,22.57,percent of total billed charges,,,60,,14.26,percent of total billed charges,,14.26,22.57,
oxymetazoline Nasal 0.05% Spry 15 mL [KHKS],6192366,CDM,250,RC,11523-1159-01,NDC,,,Inpatient,15,EA,23.76,,,,80,,19.01,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,18.46,percent of total billed charges,,,95,,22.57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,22.57,
ropinirole 0.25 mg Tab [KHKS],6192367,CDM,250,RC,00904-6373-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
ropinirole 0.25 mg Tab [KHKS],6192367,CDM,250,RC,00904-6373-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
lidocaine-prilocaine Top 2.5%-2.5% Cream 30 gm[KHKS],6192368,CDM,250,RC,50383-0667-30,NDC,,,Outpatient,1,EA,5.31,,,,80,,4.25,percent of total billed charges,,,,85,4.51,percent of total billed charges,,,77.7,,4.13,percent of total billed charges,,,95,,5.05,percent of total billed charges,,,60,,3.19,percent of total billed charges,,3.19,5.05,
lidocaine-prilocaine Top 2.5%-2.5% Cream 30 gm[KHKS],6192368,CDM,250,RC,50383-0667-30,NDC,,,Inpatient,1,EA,5.31,,,,80,,4.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.13,percent of total billed charges,,,95,,5.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.05,
norEPINEPHrine 1 mg/mL IV Sol 4 mL [KHKS],6192372,CDM,250,RC,70121-1576-07,NDC,,,Outpatient,4,ML,64.87,,,,80,,51.9,percent of total billed charges,,,,85,55.14,percent of total billed charges,,,77.7,,50.41,percent of total billed charges,,,95,,61.63,percent of total billed charges,,,60,,38.92,percent of total billed charges,,38.92,61.63,
norEPINEPHrine 1 mg/mL IV Sol 4 mL [KHKS],6192372,CDM,250,RC,70121-1576-07,NDC,,,Inpatient,4,ML,64.87,,,,80,,51.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,50.41,percent of total billed charges,,,95,,61.63,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,61.63,
memantine 10 mg Tab [KHKS],6192373,CDM,250,RC,00904-6506-61,NDC,,,Outpatient,1,EA,2.86,,,,80,,2.29,percent of total billed charges,,,,85,2.43,percent of total billed charges,,,77.7,,2.22,percent of total billed charges,,,95,,2.72,percent of total billed charges,,,60,,1.72,percent of total billed charges,,1.72,2.72,
memantine 10 mg Tab [KHKS],6192373,CDM,250,RC,00904-6506-61,NDC,,,Inpatient,1,EA,2.86,,,,80,,2.29,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.22,percent of total billed charges,,,95,,2.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.72,
sodium biphosphate-sodium phosphate 19 g-7 g Rectal Enema 133 mL [KHKS],6192374,CDM,250,RC,00132-0201-40,NDC,,,Outpatient,133,ML,3.48,,,,80,,2.78,percent of total billed charges,,,,85,2.96,percent of total billed charges,,,77.7,,2.7,percent of total billed charges,,,95,,3.31,percent of total billed charges,,,60,,2.09,percent of total billed charges,,2.09,3.31,
sodium biphosphate-sodium phosphate 19 g-7 g Rectal Enema 133 mL [KHKS],6192374,CDM,250,RC,00132-0201-40,NDC,,,Inpatient,133,ML,3.48,,,,80,,2.78,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.7,percent of total billed charges,,,95,,3.31,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.31,
gabapentin 100 mg Cap [KHKS],6192375,CDM,250,RC,00904-6665-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
gabapentin 100 mg Cap [KHKS],6192375,CDM,250,RC,00904-6665-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
Dextrose 5% with 0.225% NaCl IV Sol 1000 mL [KHKS],6192376,CDM,250,RC,00990-7924-09,NDC,,,Outpatient,1000,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,85,16.07,percent of total billed charges,,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,60,,11.34,percent of total billed charges,,11.34,17.96,
Dextrose 5% with 0.225% NaCl IV Sol 1000 mL [KHKS],6192376,CDM,250,RC,00990-7924-09,NDC,,,Inpatient,1000,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.96,
levofloxacin 500 mg Tab [KHKS],6192377,CDM,250,RC,00904-6352-61,NDC,,,Outpatient,1,EA,50.46,,,,80,,40.37,percent of total billed charges,,,,85,42.89,percent of total billed charges,,,77.7,,39.21,percent of total billed charges,,,95,,47.94,percent of total billed charges,,,60,,30.28,percent of total billed charges,,30.28,47.94,
levofloxacin 500 mg Tab [KHKS],6192377,CDM,250,RC,00904-6352-61,NDC,,,Inpatient,1,EA,50.46,,,,80,,40.37,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,39.21,percent of total billed charges,,,95,,47.94,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,47.94,
HYDROmorphone 4 mg Tab [KHKS],6192378,CDM,250,RC,42858-0302-25,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
HYDROmorphone 4 mg Tab [KHKS],6192378,CDM,250,RC,42858-0302-25,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
phenylephrine 10 mg/mL Inj Sol [KHKS],6192379,CDM,636,RC,J2371,HCPCS,63323-0751-13,NDC,Outpatient,1,ML,11.52,,,,80,,9.22,percent of total billed charges,,,,85,9.79,percent of total billed charges,,,77.7,,8.95,percent of total billed charges,,,95,,10.94,percent of total billed charges,,,60,,6.91,percent of total billed charges,,6.91,10.94,
phenylephrine 10 mg/mL Inj Sol [KHKS],6192379,CDM,636,RC,J2371,HCPCS,63323-0751-13,NDC,Inpatient,1,ML,11.52,,,,80,,9.22,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.95,percent of total billed charges,,,95,,10.94,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.94,
baclofen 10 mg Tab [KHKS],6192380,CDM,250,RC,63739-0479-10,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
baclofen 10 mg Tab [KHKS],6192380,CDM,250,RC,63739-0479-10,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
ropivacaine 0.2% (2 mg/mL) Inj Sol 200 mL [KHKS],6192381,CDM,636,RC,J2795,HCPCS,63323-0285-64,NDC,Outpatient,200,ML,294,,,,80,,235.2,percent of total billed charges,,,,50,0.06,fee schedule,,,77.7,,228.44,percent of total billed charges,,,95,,279.3,percent of total billed charges,,,60,,176.4,percent of total billed charges,,0.06,279.3,
ropivacaine 0.2% (2 mg/mL) Inj Sol 200 mL [KHKS],6192381,CDM,636,RC,J2795,HCPCS,63323-0285-64,NDC,Inpatient,200,ML,294,,,,80,,235.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,228.44,percent of total billed charges,,,95,,279.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,279.3,
carboprost 250 mcg/mL Inj Sol 1 mL [KHKS],6192382,CDM,250,RC,00009-0856-08,NDC,,,Outpatient,1,ML,786.84,,,,80,,629.47,percent of total billed charges,,,,85,668.81,percent of total billed charges,,,77.7,,611.38,percent of total billed charges,,,95,,747.5,percent of total billed charges,,,60,,472.11,percent of total billed charges,,472.11,747.5,
carboprost 250 mcg/mL Inj Sol 1 mL [KHKS],6192382,CDM,250,RC,00009-0856-08,NDC,,,Inpatient,1,ML,786.84,,,,80,,629.47,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,611.38,percent of total billed charges,,,95,,747.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,747.5,
fentaNYL 25 mcg/hr Patch [KHKS],6192383,CDM,250,RC,47781-0424-47,NDC,,,Outpatient,1,EA,63.8,,,,80,,51.04,percent of total billed charges,,,,85,54.23,percent of total billed charges,,,77.7,,49.57,percent of total billed charges,,,95,,60.61,percent of total billed charges,,,60,,38.28,percent of total billed charges,,38.28,60.61,
fentaNYL 25 mcg/hr Patch [KHKS],6192383,CDM,250,RC,47781-0424-47,NDC,,,Inpatient,1,EA,63.8,,,,80,,51.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,49.57,percent of total billed charges,,,95,,60.61,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,60.61,
simethicone 40 mg/0.6 mL Oral Liq 30 mL [KHKS],6192384,CDM,250,RC,49348-0740-27,NDC,,,Outpatient,30,ML,24.57,,,,80,,19.66,percent of total billed charges,,,,85,20.88,percent of total billed charges,,,77.7,,19.09,percent of total billed charges,,,95,,23.34,percent of total billed charges,,,60,,14.74,percent of total billed charges,,14.74,23.34,
simethicone 40 mg/0.6 mL Oral Liq 30 mL [KHKS],6192384,CDM,250,RC,49348-0740-27,NDC,,,Inpatient,30,ML,24.57,,,,80,,19.66,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.09,percent of total billed charges,,,95,,23.34,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,23.34,
lubiprostone 24 mcg oral Cap [KHKS],6192385,CDM,250,RC,00254-3029-02,NDC,,,Outpatient,1,EA,20.04,,,,80,,16.03,percent of total billed charges,,,,85,17.03,percent of total billed charges,,,77.7,,15.57,percent of total billed charges,,,95,,19.04,percent of total billed charges,,,60,,12.02,percent of total billed charges,,12.02,19.04,
lubiprostone 24 mcg oral Cap [KHKS],6192385,CDM,250,RC,00254-3029-02,NDC,,,Inpatient,1,EA,20.04,,,,80,,16.03,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,15.57,percent of total billed charges,,,95,,19.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,19.04,
midodrine 5 mg Tab [KHKS],6192386,CDM,250,RC,00245-0212-01,NDC,,,Outpatient,1,EA,13.46,,,,80,,10.77,percent of total billed charges,,,,85,11.44,percent of total billed charges,,,77.7,,10.46,percent of total billed charges,,,95,,12.79,percent of total billed charges,,,60,,8.08,percent of total billed charges,,8.08,12.79,
midodrine 5 mg Tab [KHKS],6192386,CDM,250,RC,00245-0212-01,NDC,,,Inpatient,1,EA,13.46,,,,80,,10.77,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.46,percent of total billed charges,,,95,,12.79,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,12.79,
labetalol 5 mg/mL IV Sol 40 mL [KHKS],6192387,CDM,636,RC,J1920,HCPCS,00143-9623-01,NDC,Outpatient,1,ML,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
labetalol 5 mg/mL IV Sol 40 mL [KHKS],6192387,CDM,636,RC,J1920,HCPCS,00143-9623-01,NDC,Inpatient,1,ML,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
alendronate 70 mg Tab [KHKS],6192388,CDM,250,RC,16714-0633-01,NDC,,,Outpatient,1,EA,61.24,,,,80,,48.99,percent of total billed charges,,,,85,52.05,percent of total billed charges,,,77.7,,47.58,percent of total billed charges,,,95,,58.18,percent of total billed charges,,,60,,36.74,percent of total billed charges,,36.74,58.18,
alendronate 70 mg Tab [KHKS],6192388,CDM,250,RC,16714-0633-01,NDC,,,Inpatient,1,EA,61.24,,,,80,,48.99,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,47.58,percent of total billed charges,,,95,,58.18,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,58.18,
heparin flush 100 units/mL Sol 5 mL [KHKS],6192389,CDM,636,RC,J1642,HCPCS,08290-3064-24,NDC,Outpatient,5,ML,2.5,,,,80,,2,percent of total billed charges,,,,50,0.01,fee schedule,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,0.01,2.38,
heparin flush 100 units/mL Sol 5 mL [KHKS],6192389,CDM,636,RC,J1642,HCPCS,08290-3064-24,NDC,Inpatient,5,ML,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
guaiFENesin 600 mg ER Tab [KHKS],6192390,CDM,250,RC,16714-0633-01,NDC,,,Outpatient,1,EA,3.2,,,,80,,2.56,percent of total billed charges,,,,85,2.72,percent of total billed charges,,,77.7,,2.49,percent of total billed charges,,,95,,3.04,percent of total billed charges,,,60,,1.92,percent of total billed charges,,1.92,3.04,
guaiFENesin 600 mg ER Tab [KHKS],6192390,CDM,250,RC,16714-0633-01,NDC,,,Inpatient,1,EA,3.2,,,,80,,2.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.49,percent of total billed charges,,,95,,3.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.04,
citric acid-sodium citrate 334 mg-500 mg/5 mL Oral Sol 15 mL [KHKS],6192391,CDM,250,RC,16714-0633-01,NDC,,,Outpatient,15,ML,6.03,,,,80,,4.82,percent of total billed charges,,,,85,5.13,percent of total billed charges,,,77.7,,4.69,percent of total billed charges,,,95,,5.73,percent of total billed charges,,,60,,3.62,percent of total billed charges,,3.62,5.73,
citric acid-sodium citrate 334 mg-500 mg/5 mL Oral Sol 15 mL [KHKS],6192391,CDM,250,RC,16714-0633-01,NDC,,,Inpatient,15,ML,6.03,,,,80,,4.82,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.69,percent of total billed charges,,,95,,5.73,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.73,
sucralfate 1 g Tab [KHKS],6192392,CDM,250,RC,16714-0633-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
sucralfate 1 g Tab [KHKS],6192392,CDM,250,RC,16714-0633-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
metroNIDAZOLE 250 mg Tab [KHKS],6192393,CDM,250,RC,16714-0633-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
metroNIDAZOLE 250 mg Tab [KHKS],6192393,CDM,250,RC,16714-0633-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
fosfomycin 3 gm Packet [KHKS],6192395,CDM,250,RC,16714-0633-01,NDC,,,Outpatient,1,EA,225.9,,,,80,,180.72,percent of total billed charges,,,,85,192.02,percent of total billed charges,,,77.7,,175.52,percent of total billed charges,,,95,,214.61,percent of total billed charges,,,60,,135.54,percent of total billed charges,,135.54,214.61,
fosfomycin 3 gm Packet [KHKS],6192395,CDM,250,RC,16714-0633-01,NDC,,,Inpatient,1,EA,225.9,,,,80,,180.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,175.52,percent of total billed charges,,,95,,214.61,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,214.61,
dapagliflozin 5 mg Tab [KHKS],6192397,CDM,250,RC,16714-0633-01,NDC,,,Outpatient,1,EA,65.86,,,,80,,52.69,percent of total billed charges,,,,85,55.98,percent of total billed charges,,,77.7,,51.17,percent of total billed charges,,,95,,62.57,percent of total billed charges,,,60,,39.52,percent of total billed charges,,39.52,62.57,
dapagliflozin 5 mg Tab [KHKS],6192397,CDM,250,RC,16714-0633-01,NDC,,,Inpatient,1,EA,65.86,,,,80,,52.69,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,51.17,percent of total billed charges,,,95,,62.57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,62.57,
thiamine 100 mg/mL Inj Sol 2 mL [KHKS],6192398,CDM,636,RC,J3411,HCPCS,63323-0013-09,NDC,Outpatient,2,ML,37.31,,,,80,,29.85,percent of total billed charges,,,,50,1.81,fee schedule,,,77.7,,28.99,percent of total billed charges,,,95,,35.45,percent of total billed charges,,,60,,22.39,percent of total billed charges,,1.81,35.45,
thiamine 100 mg/mL Inj Sol 2 mL [KHKS],6192398,CDM,636,RC,J3411,HCPCS,63323-0013-09,NDC,Inpatient,2,ML,37.31,,,,80,,29.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,28.99,percent of total billed charges,,,95,,35.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,35.45,
LORazepam 0.5 mg Tab [KHKS],6192399,CDM,250,RC,69315-0904-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
LORazepam 0.5 mg Tab [KHKS],6192399,CDM,250,RC,69315-0904-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
diphenhydrAMINE 25 mg Cap [KHKS],6192401,CDM,250,RC,00904-5306-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
diphenhydrAMINE 25 mg Cap [KHKS],6192401,CDM,250,RC,00904-5306-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
carvedilol 6.25 mg Tab [KHKS],6192403,CDM,250,RC,00904-6301-61,NDC,,,Outpatient,1,EA,6.3,,,,80,,5.04,percent of total billed charges,,,,85,5.36,percent of total billed charges,,,77.7,,4.9,percent of total billed charges,,,95,,5.99,percent of total billed charges,,,60,,3.78,percent of total billed charges,,3.78,5.99,
carvedilol 6.25 mg Tab [KHKS],6192403,CDM,250,RC,00904-6301-61,NDC,,,Inpatient,1,EA,6.3,,,,80,,5.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.9,percent of total billed charges,,,95,,5.99,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.99,
cefepime 1 g Inj [KHKS],6192404,CDM,636,RC,J0692,HCPCS,60505-6144-04,NDC,Outpatient,1,EA,61,,,,80,,48.8,percent of total billed charges,,,,50,0.97,fee schedule,,,77.7,,47.4,percent of total billed charges,,,95,,57.95,percent of total billed charges,,,60,,36.6,percent of total billed charges,,0.97,57.95,
cefepime 1 g Inj [KHKS],6192404,CDM,636,RC,J0692,HCPCS,60505-6144-04,NDC,Inpatient,1,EA,61,,,,80,,48.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,47.4,percent of total billed charges,,,95,,57.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,57.95,
Sodium Chloride 0.45% IV Sol 1000 mL [KHKS],6192405,CDM,250,RC,00990-7985-09,NDC,,,Outpatient,1000,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,85,16.07,percent of total billed charges,,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,60,,11.34,percent of total billed charges,,11.34,17.96,
Sodium Chloride 0.45% IV Sol 1000 mL [KHKS],6192405,CDM,250,RC,00990-7985-09,NDC,,,Inpatient,1000,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.96,
labetalol 100 mg Tab [KHKS],6192406,CDM,250,RC,00904-7109-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
labetalol 100 mg Tab [KHKS],6192406,CDM,250,RC,00904-7109-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
lidocaine Top 2% 20 mg/mL (MM) Sol 100 mL [KHKS],6192407,CDM,250,RC,50383-0775-04,NDC,,,Outpatient,1,ML,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
lidocaine Top 2% 20 mg/mL (MM) Sol 100 mL [KHKS],6192407,CDM,250,RC,50383-0775-04,NDC,,,Inpatient,1,ML,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
atorvastatin 10 mg Tab [KHKS],6192408,CDM,250,RC,00904-6290-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
atorvastatin 10 mg Tab [KHKS],6192408,CDM,250,RC,00904-6290-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
folic acid 0.4 mg Tab [KHKS],6192409,CDM,250,RC,10939-8934-04,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
folic acid 0.4 mg Tab [KHKS],6192409,CDM,250,RC,10939-8934-04,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
folic acid 5 mg/mL Inj Sol 10 mL MDV [KHKS],6192410,CDM,250,RC,39822-1100-01,NDC,,,Outpatient,1,ML,13.13,,,,80,,10.5,percent of total billed charges,,,,85,11.16,percent of total billed charges,,,77.7,,10.2,percent of total billed charges,,,95,,12.47,percent of total billed charges,,,60,,7.88,percent of total billed charges,,7.88,12.47,
folic acid 5 mg/mL Inj Sol 10 mL MDV [KHKS],6192410,CDM,250,RC,39822-1100-01,NDC,,,Inpatient,1,ML,13.13,,,,80,,10.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.2,percent of total billed charges,,,95,,12.47,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,12.47,
phenytoin 50 mg/mL Inj Sol 2 mL [KHKS],6192411,CDM,636,RC,J1165,HCPCS,00641-0493-25,NDC,Outpatient,2,ML,5.1,,,,80,,4.08,percent of total billed charges,,,,50,0.36,fee schedule,,,77.7,,3.96,percent of total billed charges,,,95,,4.84,percent of total billed charges,,,60,,3.06,percent of total billed charges,,0.36,4.84,
phenytoin 50 mg/mL Inj Sol 2 mL [KHKS],6192411,CDM,636,RC,J1165,HCPCS,00641-0493-25,NDC,Inpatient,2,ML,5.1,,,,80,,4.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.96,percent of total billed charges,,,95,,4.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.84,
lidocaine 1% 10 mg/mL PF Inj Sol 2 mL [KHKS],6192412,CDM,250,RC,63323-0492-27,NDC,,,Outpatient,2,ML,8.03,,,,80,,6.42,percent of total billed charges,,,,85,6.83,percent of total billed charges,,,77.7,,6.24,percent of total billed charges,,,95,,7.63,percent of total billed charges,,,60,,4.82,percent of total billed charges,,4.82,7.63,
lidocaine 1% 10 mg/mL PF Inj Sol 2 mL [KHKS],6192412,CDM,250,RC,63323-0492-27,NDC,,,Inpatient,2,ML,8.03,,,,80,,6.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.24,percent of total billed charges,,,95,,7.63,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.63,
sertraline 50 mg Tab [KHKS],6192413,CDM,250,RC,60687-0242-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
sertraline 50 mg Tab [KHKS],6192413,CDM,250,RC,60687-0242-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
enoxaparin 100 mg/mL Sol Syringe [KHKS],6192414,CDM,636,RC,J1650,HCPCS,63323-0605-94,NDC,Outpatient,1,ML,71.57,,,,80,,57.25,percent of total billed charges,,,,50,0.52,fee schedule,,,77.7,,55.61,percent of total billed charges,,,95,,67.99,percent of total billed charges,,,60,,42.94,percent of total billed charges,,0.52,67.99,
enoxaparin 100 mg/mL Sol Syringe [KHKS],6192414,CDM,636,RC,J1650,HCPCS,63323-0605-94,NDC,Inpatient,1,ML,71.57,,,,80,,57.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,55.61,percent of total billed charges,,,95,,67.99,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,67.99,
electrolyte replacement Oral Sol 1000 mL [KHKS],6192415,CDM,250,RC,49348-0570-41,NDC,,,Outpatient,1000,ML,13.77,,,,80,,11.02,percent of total billed charges,,,,85,11.7,percent of total billed charges,,,77.7,,10.7,percent of total billed charges,,,95,,13.08,percent of total billed charges,,,60,,8.26,percent of total billed charges,,8.26,13.08,
electrolyte replacement Oral Sol 1000 mL [KHKS],6192415,CDM,250,RC,49348-0570-41,NDC,,,Inpatient,1000,ML,13.77,,,,80,,11.02,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.7,percent of total billed charges,,,95,,13.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.08,
bisacodyl 10 mg Supp [KHKS],6192416,CDM,250,RC,00574-7050-12,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
bisacodyl 10 mg Supp [KHKS],6192416,CDM,250,RC,00574-7050-12,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
doxazosin 1 mg Tab [KHKS],6192417,CDM,250,RC,00904-5522-61,NDC,,,Outpatient,1,EA,3.05,,,,80,,2.44,percent of total billed charges,,,,85,2.59,percent of total billed charges,,,77.7,,2.37,percent of total billed charges,,,95,,2.9,percent of total billed charges,,,60,,1.83,percent of total billed charges,,1.83,2.9,
doxazosin 1 mg Tab [KHKS],6192417,CDM,250,RC,00904-5522-61,NDC,,,Inpatient,1,EA,3.05,,,,80,,2.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.37,percent of total billed charges,,,95,,2.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.9,
Dextrose 5% in Lactated Ringers IV Sol 1000 mL [KHKS],6192418,CDM,636,RC,J7121,HCPCS,00990-7929-09,NDC,Outpatient,1000,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,50,4.45,fee schedule,,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,60,,11.34,percent of total billed charges,,4.45,17.96,
Dextrose 5% in Lactated Ringers IV Sol 1000 mL [KHKS],6192418,CDM,636,RC,J7121,HCPCS,00990-7929-09,NDC,Inpatient,1000,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.96,
promethazine 6.25 mg/5 mL Oral Syrup 473 mL [KHKS],6192419,CDM,250,RC,60432-0608-16,NDC,,,Outpatient,5,ML,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
promethazine 6.25 mg/5 mL Oral Syrup 473 mL [KHKS],6192419,CDM,250,RC,60432-0608-16,NDC,,,Inpatient,5,ML,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
calcium carb/Mg hydroxide/simethicone (Mylanta Tonight) 355 mL [KHKS],6192421,CDM,250,RC,62372-0510-12,NDC,,,Outpatient,10,ML,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
calcium carb/Mg hydroxide/simethicone (Mylanta Tonight) 355 mL [KHKS],6192421,CDM,250,RC,62372-0510-12,NDC,,,Inpatient,10,ML,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
naproxen 500 mg Tab [KHKS],6192422,CDM,250,RC,68462-0190-01,NDC,,,Outpatient,1,EA,3.89,,,,80,,3.11,percent of total billed charges,,,,85,3.31,percent of total billed charges,,,77.7,,3.02,percent of total billed charges,,,95,,3.69,percent of total billed charges,,,60,,2.33,percent of total billed charges,,2.33,3.69,
naproxen 500 mg Tab [KHKS],6192422,CDM,250,RC,68462-0190-01,NDC,,,Inpatient,1,EA,3.89,,,,80,,3.11,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.02,percent of total billed charges,,,95,,3.69,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.69,
simvastatin 10 mg Tab [KHKS],6192424,CDM,250,RC,16714-0682-02,NDC,,,Outpatient,1,EA,8.31,,,,80,,6.65,percent of total billed charges,,,,85,7.06,percent of total billed charges,,,77.7,,6.45,percent of total billed charges,,,95,,7.89,percent of total billed charges,,,60,,4.98,percent of total billed charges,,4.98,7.89,
simvastatin 10 mg Tab [KHKS],6192424,CDM,250,RC,16714-0682-02,NDC,,,Inpatient,1,EA,8.31,,,,80,,6.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.45,percent of total billed charges,,,95,,7.89,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.89,
ocular lubricant Gel (Refresh Celluvisc Lubricant eye gel) [KHKS],6192425,CDM,250,RC,00023-4554-30,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
ocular lubricant Gel (Refresh Celluvisc Lubricant eye gel) [KHKS],6192425,CDM,250,RC,00023-4554-30,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
haloperidol 5 mg/mL Inj Sol 1 mL [KHKS],6192426,CDM,636,RC,J1630,HCPCS,67457-0426-12,NDC,Outpatient,1,ML,4.32,,,,80,,3.46,percent of total billed charges,,,,50,0.75,fee schedule,,,77.7,,3.36,percent of total billed charges,,,95,,4.1,percent of total billed charges,,,60,,2.59,percent of total billed charges,,0.75,4.1,
haloperidol 5 mg/mL Inj Sol 1 mL [KHKS],6192426,CDM,636,RC,J1630,HCPCS,67457-0426-12,NDC,Inpatient,1,ML,4.32,,,,80,,3.46,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.36,percent of total billed charges,,,95,,4.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.1,
sterile water IRRIG Sol 1500 mL [KHKS],6192427,CDM,250,RC,00990-7139-36,NDC,,,Outpatient,1500,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,85,16.07,percent of total billed charges,,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,60,,11.34,percent of total billed charges,,11.34,17.96,
sterile water IRRIG Sol 1500 mL [KHKS],6192427,CDM,250,RC,00990-7139-36,NDC,,,Inpatient,1500,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.96,
acetaminophen 120 mg Supp [KHKS],6192428,CDM,250,RC,45802-0732-30,NDC,,,Outpatient,1,UN,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
acetaminophen 120 mg Supp [KHKS],6192428,CDM,250,RC,45802-0732-30,NDC,,,Inpatient,1,UN,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
HYDROmorphone 2 mg/mL Inj Sol 1 mL [KHKS],6192429,CDM,636,RC,J1171,HCPCS,00409-3365-10,NDC,Outpatient,1,ML,5.78,,,,80,,4.62,percent of total billed charges,,,,85,4.91,percent of total billed charges,,,77.7,,4.49,percent of total billed charges,,,95,,5.49,percent of total billed charges,,,60,,3.47,percent of total billed charges,,3.47,5.49,
HYDROmorphone 2 mg/mL Inj Sol 1 mL [KHKS],6192429,CDM,636,RC,J1171,HCPCS,00409-3365-10,NDC,Inpatient,1,ML,5.78,,,,80,,4.62,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.49,percent of total billed charges,,,95,,5.49,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.49,
doxycycline hyclate 100 mg Tab [KHKS],6192430,CDM,250,RC,42806-0312-05,NDC,,,Outpatient,1,EA,18.44,,,,80,,14.75,percent of total billed charges,,,,85,15.67,percent of total billed charges,,,77.7,,14.33,percent of total billed charges,,,95,,17.52,percent of total billed charges,,,60,,11.06,percent of total billed charges,,11.06,17.52,
doxycycline hyclate 100 mg Tab [KHKS],6192430,CDM,250,RC,42806-0312-05,NDC,,,Inpatient,1,EA,18.44,,,,80,,14.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.33,percent of total billed charges,,,95,,17.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.52,
cefTAZidime 1 g Inj [KHKS],6192431,CDM,636,RC,J0713,HCPCS,44567-0235-25,NDC,Outpatient,1,EA,16.2,,,,80,,12.96,percent of total billed charges,,,,50,1.5,fee schedule,,,77.7,,12.59,percent of total billed charges,,,95,,15.39,percent of total billed charges,,,60,,9.72,percent of total billed charges,,1.5,15.39,
cefTAZidime 1 g Inj [KHKS],6192431,CDM,636,RC,J0713,HCPCS,44567-0235-25,NDC,Inpatient,1,EA,16.2,,,,80,,12.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.59,percent of total billed charges,,,95,,15.39,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.39,
lidocaine Top 5% Patch [KHKS],6192432,CDM,250,RC,42858-0118-30,NDC,,,Outpatient,1,EA,7.8,,,,80,,6.24,percent of total billed charges,,,,85,6.63,percent of total billed charges,,,77.7,,6.06,percent of total billed charges,,,95,,7.41,percent of total billed charges,,,60,,4.68,percent of total billed charges,,4.68,7.41,
lidocaine Top 5% Patch [KHKS],6192432,CDM,250,RC,42858-0118-30,NDC,,,Inpatient,1,EA,7.8,,,,80,,6.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.06,percent of total billed charges,,,95,,7.41,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.41,
clarithromycin 500 mg Tab [KHKS],6192435,CDM,250,RC,50268-0179-13,NDC,,,Outpatient,1,EA,20.98,,,,80,,16.79,percent of total billed charges,,,,85,17.83,percent of total billed charges,,,77.7,,16.3,percent of total billed charges,,,95,,19.93,percent of total billed charges,,,60,,12.59,percent of total billed charges,,12.59,19.93,
clarithromycin 500 mg Tab [KHKS],6192435,CDM,250,RC,50268-0179-13,NDC,,,Inpatient,1,EA,20.98,,,,80,,16.79,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,16.3,percent of total billed charges,,,95,,19.93,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,19.93,
phenytoin 100 mg ER Cap [KHKS],6192436,CDM,250,RC,00904-6187-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
phenytoin 100 mg ER Cap [KHKS],6192436,CDM,250,RC,00904-6187-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
azaTHIOprine 50 mg Tab [KHKS],6192437,CDM,250,RC,68084-0229-01,NDC,,,Outpatient,1,EA,2.54,,,,80,,2.03,percent of total billed charges,,,,85,2.16,percent of total billed charges,,,77.7,,1.97,percent of total billed charges,,,95,,2.41,percent of total billed charges,,,60,,1.52,percent of total billed charges,,1.52,2.41,
azaTHIOprine 50 mg Tab [KHKS],6192437,CDM,250,RC,68084-0229-01,NDC,,,Inpatient,1,EA,2.54,,,,80,,2.03,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.97,percent of total billed charges,,,95,,2.41,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.41,
triamcinolone 10 mg/mL Inj Susp 5 mL [KHKS],6192438,CDM,636,RC,J3301,HCPCS,00003-0494-20,NDC,Outpatient,5,ML,43.53,,,,80,,34.82,percent of total billed charges,,,,50,0.68,fee schedule,,,77.7,,33.82,percent of total billed charges,,,95,,41.35,percent of total billed charges,,,60,,26.12,percent of total billed charges,,0.68,41.35,
triamcinolone 10 mg/mL Inj Susp 5 mL [KHKS],6192438,CDM,636,RC,J3301,HCPCS,00003-0494-20,NDC,Inpatient,5,ML,43.53,,,,80,,34.82,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,33.82,percent of total billed charges,,,95,,41.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,41.35,
albuterol-ipratropium 100 mcg-20 mcg/inh Aer 4 gm [KHKS],6192439,CDM,250,RC,00597-0024-02,NDC,,,Outpatient,4,EA,1023.98,,,,80,,819.18,percent of total billed charges,,,,85,870.38,percent of total billed charges,,,77.7,,795.63,percent of total billed charges,,,95,,972.78,percent of total billed charges,,,60,,614.39,percent of total billed charges,,614.39,972.78,
albuterol-ipratropium 100 mcg-20 mcg/inh Aer 4 gm [KHKS],6192439,CDM,250,RC,00597-0024-02,NDC,,,Inpatient,4,EA,1023.98,,,,80,,819.18,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,795.63,percent of total billed charges,,,95,,972.78,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,972.78,
butorphanol 2 mg/mL Inj Sol 1mL [KHKS],6192440,CDM,636,RC,J0595,HCPCS,00409-1626-01,NDC,Outpatient,1,ML,22.31,,,,80,,17.85,percent of total billed charges,,,,50,2.28,fee schedule,,,77.7,,17.33,percent of total billed charges,,,95,,21.19,percent of total billed charges,,,60,,13.38,percent of total billed charges,,2.28,21.19,
butorphanol 2 mg/mL Inj Sol 1mL [KHKS],6192440,CDM,636,RC,J0595,HCPCS,00409-1626-01,NDC,Inpatient,1,ML,22.31,,,,80,,17.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,17.33,percent of total billed charges,,,95,,21.19,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,21.19,
tamsulosin 0.4 mg Oral Cap [KHKS],6192441,CDM,250,RC,63739-0567-10,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
tamsulosin 0.4 mg Oral Cap [KHKS],6192441,CDM,250,RC,63739-0567-10,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
calcium carbonate 500 mg Chew Tab [KHKS],6192442,CDM,250,RC,66553-0004-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
calcium carbonate 500 mg Chew Tab [KHKS],6192442,CDM,250,RC,66553-0004-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
fenofibric acid 135 mg Cap [KHKS],6192443,CDM,250,RC,62332-0245-90,NDC,,,Outpatient,1,EA,17.99,,,,80,,14.39,percent of total billed charges,,,,85,15.29,percent of total billed charges,,,77.7,,13.97,percent of total billed charges,,,95,,17.09,percent of total billed charges,,,60,,10.79,percent of total billed charges,,10.79,17.09,
fenofibric acid 135 mg Cap [KHKS],6192443,CDM,250,RC,62332-0245-90,NDC,,,Inpatient,1,EA,17.99,,,,80,,14.39,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,13.97,percent of total billed charges,,,95,,17.09,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.09,
lidocaine Top 2% Gel w/Appl 10 mL [KHKS],6192445,CDM,250,RC,76329-3013-05,NDC,,,Outpatient,10,EA,23.08,,,,80,,18.46,percent of total billed charges,,,,85,19.62,percent of total billed charges,,,77.7,,17.93,percent of total billed charges,,,95,,21.92,percent of total billed charges,,,60,,13.85,percent of total billed charges,,13.85,21.92,
lidocaine Top 2% Gel w/Appl 10 mL [KHKS],6192445,CDM,250,RC,76329-3013-05,NDC,,,Inpatient,10,EA,23.08,,,,80,,18.46,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,17.93,percent of total billed charges,,,95,,21.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,21.92,
Dextrose 5% with 0.45% NaCl and KCl 40 mEq/l IV PREMIX Sol 1000 mL [KHKS],6192446,CDM,636,RC,J3480,HCPCS,00990-7904-09,NDC,Outpatient,1000,ML,25.45,,,,80,,20.36,percent of total billed charges,,,,50,0.09,fee schedule,,,77.7,,19.78,percent of total billed charges,,,95,,24.18,percent of total billed charges,,,60,,15.27,percent of total billed charges,,0.09,24.18,
Dextrose 5% with 0.45% NaCl and KCl 40 mEq/l IV PREMIX Sol 1000 mL [KHKS],6192446,CDM,636,RC,J3480,HCPCS,00990-7904-09,NDC,Inpatient,1000,ML,25.45,,,,80,,20.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.78,percent of total billed charges,,,95,,24.18,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,24.18,
sodium chloride 0.9% INH Sol 3 mL [KHKS],6192448,CDM,250,RC,00487-9301-03,NDC,,,Outpatient,3,ML,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
sodium chloride 0.9% INH Sol 3 mL [KHKS],6192448,CDM,250,RC,00487-9301-03,NDC,,,Inpatient,3,ML,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
divalproex sodium 125 mg Oral EC Tab [KHKS],6192449,CDM,250,RC,60687-0211-21,NDC,,,Outpatient,1,EA,2.67,,,,80,,2.14,percent of total billed charges,,,,85,2.27,percent of total billed charges,,,77.7,,2.07,percent of total billed charges,,,95,,2.54,percent of total billed charges,,,60,,1.6,percent of total billed charges,,1.6,2.54,
divalproex sodium 125 mg Oral EC Tab [KHKS],6192449,CDM,250,RC,60687-0211-21,NDC,,,Inpatient,1,EA,2.67,,,,80,,2.14,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.07,percent of total billed charges,,,95,,2.54,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.54,
levothyroxine 88 mcg (0.088 mg) Tab [KHKS],6192450,CDM,250,RC,60687-0486-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
levothyroxine 88 mcg (0.088 mg) Tab [KHKS],6192450,CDM,250,RC,60687-0486-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
traZODone 50 mg Tab [KHKS],6192451,CDM,250,RC,00904-6868-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
traZODone 50 mg Tab [KHKS],6192451,CDM,250,RC,00904-6868-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
nicotine 7 mg/24 hr Patch [KHKS],6192452,CDM,250,RC,43598-0446-74,NDC,,,Outpatient,1,EA,6.4,,,,80,,5.12,percent of total billed charges,,,,85,5.44,percent of total billed charges,,,77.7,,4.97,percent of total billed charges,,,95,,6.08,percent of total billed charges,,,60,,3.84,percent of total billed charges,,3.84,6.08,
nicotine 7 mg/24 hr Patch [KHKS],6192452,CDM,250,RC,43598-0446-74,NDC,,,Inpatient,1,EA,6.4,,,,80,,5.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.97,percent of total billed charges,,,95,,6.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.08,
vecuronium 10 mg IV Inj [KHKS],6192453,CDM,250,RC,00409-1632-01,NDC,,,Outpatient,1,EA,26.42,,,,80,,21.14,percent of total billed charges,,,,85,22.46,percent of total billed charges,,,77.7,,20.53,percent of total billed charges,,,95,,25.1,percent of total billed charges,,,60,,15.85,percent of total billed charges,,15.85,25.1,
vecuronium 10 mg IV Inj [KHKS],6192453,CDM,250,RC,00409-1632-01,NDC,,,Inpatient,1,EA,26.42,,,,80,,21.14,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,20.53,percent of total billed charges,,,95,,25.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,25.1,
etomidate 2 mg/mL IV Sol 20 mL [KHKS],6192454,CDM,250,RC,00409-6695-02,NDC,,,Outpatient,20,ML,23.35,,,,80,,18.68,percent of total billed charges,,,,85,19.85,percent of total billed charges,,,77.7,,18.14,percent of total billed charges,,,95,,22.18,percent of total billed charges,,,60,,14.01,percent of total billed charges,,14.01,22.18,
etomidate 2 mg/mL IV Sol 20 mL [KHKS],6192454,CDM,250,RC,00409-6695-02,NDC,,,Inpatient,20,ML,23.35,,,,80,,18.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,18.14,percent of total billed charges,,,95,,22.18,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,22.18,
indomethacin 25 mg Cap [KHKS],6192455,CDM,250,RC,50268-0430-15,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
indomethacin 25 mg Cap [KHKS],6192455,CDM,250,RC,50268-0430-15,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
acetaminophen-oxyCODONE 325 mg-10 mg Tab [KHKS],6192456,CDM,250,RC,68084-0710-01,NDC,,,Outpatient,1,EA,10.71,,,,80,,8.57,percent of total billed charges,,,,85,9.1,percent of total billed charges,,,77.7,,8.32,percent of total billed charges,,,95,,10.17,percent of total billed charges,,,60,,6.43,percent of total billed charges,,6.43,10.17,
acetaminophen-oxyCODONE 325 mg-10 mg Tab [KHKS],6192456,CDM,250,RC,68084-0710-01,NDC,,,Inpatient,1,EA,10.71,,,,80,,8.57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.32,percent of total billed charges,,,95,,10.17,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.17,
levothyroxine 100 mcg (0.1 mg) Pow [KHKS],6192457,CDM,636,RC,J0651,HCPCS,63323-0649-16,NDC,Outpatient,1,EA,285.08,,,,80,,228.06,percent of total billed charges,,,,85,242.32,percent of total billed charges,,,77.7,,221.5,percent of total billed charges,,,95,,270.82,percent of total billed charges,,,60,,171.05,percent of total billed charges,,171.05,270.82,
levothyroxine 100 mcg (0.1 mg) Pow [KHKS],6192457,CDM,636,RC,J0651,HCPCS,63323-0649-16,NDC,Inpatient,1,EA,285.08,,,,80,,228.06,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,221.5,percent of total billed charges,,,95,,270.82,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,270.82,
chlorhexidine Top 4% Soap 15 mL [KHKS],6192458,CDM,250,RC,00234-0575-17,NDC,,,Outpatient,15,EA,4,,,,80,,3.2,percent of total billed charges,,,,85,3.4,percent of total billed charges,,,77.7,,3.11,percent of total billed charges,,,95,,3.8,percent of total billed charges,,,60,,2.4,percent of total billed charges,,2.4,3.8,
chlorhexidine Top 4% Soap 15 mL [KHKS],6192458,CDM,250,RC,00234-0575-17,NDC,,,Inpatient,15,EA,4,,,,80,,3.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.11,percent of total billed charges,,,95,,3.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.8,
loperamide 2 mg Cap [KHKS],6192459,CDM,250,RC,60687-0229-01,NDC,,,Outpatient,1,EA,3.06,,,,80,,2.45,percent of total billed charges,,,,85,2.6,percent of total billed charges,,,77.7,,2.38,percent of total billed charges,,,95,,2.91,percent of total billed charges,,,60,,1.84,percent of total billed charges,,1.84,2.91,
loperamide 2 mg Cap [KHKS],6192459,CDM,250,RC,60687-0229-01,NDC,,,Inpatient,1,EA,3.06,,,,80,,2.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.38,percent of total billed charges,,,95,,2.91,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.91,
medroxyPROGESTERone 10 mg Tab [KHKS],6192460,CDM,250,RC,00555-0779-02,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
medroxyPROGESTERone 10 mg Tab [KHKS],6192460,CDM,250,RC,00555-0779-02,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
amoxicillin-clavulanate 875 mg-125 mg Tab [KHKS],6192462,CDM,250,RC,16714-0478-02,NDC,,,Outpatient,1,EA,14.73,,,,80,,11.78,percent of total billed charges,,,,85,12.52,percent of total billed charges,,,77.7,,11.45,percent of total billed charges,,,95,,13.99,percent of total billed charges,,,60,,8.84,percent of total billed charges,,8.84,13.99,
amoxicillin-clavulanate 875 mg-125 mg Tab [KHKS],6192462,CDM,250,RC,16714-0478-02,NDC,,,Inpatient,1,EA,14.73,,,,80,,11.78,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.45,percent of total billed charges,,,95,,13.99,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.99,
atropine 0.1 mg/mL Inj Sol 10 mL Syringe [KHKS],6192463,CDM,636,RC,J0461,HCPCS,76329-3340-01,NDC,Outpatient,10,ML,37.51,,,,80,,30.01,percent of total billed charges,,,,50,0.07,fee schedule,,,77.7,,29.15,percent of total billed charges,,,95,,35.64,percent of total billed charges,,,60,,22.51,percent of total billed charges,,0.07,35.64,
atropine 0.1 mg/mL Inj Sol 10 mL Syringe [KHKS],6192463,CDM,636,RC,J0461,HCPCS,76329-3340-01,NDC,Inpatient,10,ML,37.51,,,,80,,30.01,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,29.15,percent of total billed charges,,,95,,35.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,35.64,
clopidogrel 75 mg Tab [KHKS],6192464,CDM,250,RC,00904-6294-61,NDC,,,Outpatient,1,EA,13.09,,,,80,,10.47,percent of total billed charges,,,,85,11.13,percent of total billed charges,,,77.7,,10.17,percent of total billed charges,,,95,,12.43,percent of total billed charges,,,60,,7.85,percent of total billed charges,,7.85,12.43,
clopidogrel 75 mg Tab [KHKS],6192464,CDM,250,RC,00904-6294-61,NDC,,,Inpatient,1,EA,13.09,,,,80,,10.47,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.17,percent of total billed charges,,,95,,12.43,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,12.43,
aspirin 325 mg Oral EC Tab [KHKS],6192465,CDM,250,RC,69618-0015-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
aspirin 325 mg Oral EC Tab [KHKS],6192465,CDM,250,RC,69618-0015-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
hydrochlorothiazide 12.5 mg Cap [KHKS],6192466,CDM,250,RC,29300-0130-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
hydrochlorothiazide 12.5 mg Cap [KHKS],6192466,CDM,250,RC,29300-0130-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
famciclovir 500 mg Tab [KHKS],6192467,CDM,250,RC,00093-8119-56,NDC,,,Outpatient,1,EA,38.08,,,,80,,30.46,percent of total billed charges,,,,85,32.37,percent of total billed charges,,,77.7,,29.59,percent of total billed charges,,,95,,36.18,percent of total billed charges,,,60,,22.85,percent of total billed charges,,22.85,36.18,
famciclovir 500 mg Tab [KHKS],6192467,CDM,250,RC,00093-8119-56,NDC,,,Inpatient,1,EA,38.08,,,,80,,30.46,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,29.59,percent of total billed charges,,,95,,36.18,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,36.18,
albumin human 25% IV Sol 100 mL [KHKS],6192468,CDM,636,RC,P9047,HCPCS,76125-0792-10,NDC,Outpatient,100,ML,388.8,,,,80,,311.04,percent of total billed charges,,,,50,34.96,fee schedule,,,77.7,,302.1,percent of total billed charges,,,95,,369.36,percent of total billed charges,,,60,,233.28,percent of total billed charges,,34.96,369.36,
albumin human 25% IV Sol 100 mL [KHKS],6192468,CDM,636,RC,P9047,HCPCS,76125-0792-10,NDC,Inpatient,100,ML,388.8,,,,80,,311.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,302.1,percent of total billed charges,,,95,,369.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,369.36,
ampicillin 2 g Inj [KHKS],6192469,CDM,636,RC,J0290,HCPCS,00781-9408-95,NDC,Outpatient,1,EA,50.26,,,,80,,40.21,percent of total billed charges,,,,50,0.65,fee schedule,,,77.7,,39.05,percent of total billed charges,,,95,,47.75,percent of total billed charges,,,60,,30.16,percent of total billed charges,,0.65,47.75,
ampicillin 2 g Inj [KHKS],6192469,CDM,636,RC,J0290,HCPCS,00781-9408-95,NDC,Inpatient,1,EA,50.26,,,,80,,40.21,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,39.05,percent of total billed charges,,,95,,47.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,47.75,
magnesium sulfate 20 g/500mL-sterile water PREMIX IV Sol [KHKS],6192470,CDM,636,RC,J3475,HCPCS,00409-6729-03,NDC,Outpatient,500,ML,20.46,,,,80,,16.37,percent of total billed charges,,,,50,0.51,fee schedule,,,77.7,,15.9,percent of total billed charges,,,95,,19.44,percent of total billed charges,,,60,,12.28,percent of total billed charges,,0.51,19.44,
magnesium sulfate 20 g/500mL-sterile water PREMIX IV Sol [KHKS],6192470,CDM,636,RC,J3475,HCPCS,00409-6729-03,NDC,Inpatient,500,ML,20.46,,,,80,,16.37,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,15.9,percent of total billed charges,,,95,,19.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,19.44,
clonazePAM 1 mg Tab [KHKS],6192471,CDM,250,RC,60687-0555-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
clonazePAM 1 mg Tab [KHKS],6192471,CDM,250,RC,60687-0555-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
sterile water INJ Sol 1000 mL [KHKS],6192472,CDM,636,RC,A4217,HCPCS,00990-7990-09,NDC,Outpatient,1000,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,50,1.63,fee schedule,,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,60,,11.34,percent of total billed charges,,1.63,17.96,
sterile water INJ Sol 1000 mL [KHKS],6192472,CDM,636,RC,A4217,HCPCS,00990-7990-09,NDC,Inpatient,1000,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.96,
denosumab 60 mg/mL SQ Inj Sol [KHKS],6192473,CDM,636,RC,J0897,HCPCS,55513-0710-01,NDC,Outpatient,1,ML,3279.29,,,,80,,2623.43,percent of total billed charges,,,,50,14.84,fee schedule,,,77.7,,2548.01,percent of total billed charges,,,95,,3115.33,percent of total billed charges,,,60,,1967.57,percent of total billed charges,,14.84,3115.33,
denosumab 60 mg/mL SQ Inj Sol [KHKS],6192473,CDM,636,RC,J0897,HCPCS,55513-0710-01,NDC,Inpatient,1,ML,3279.29,,,,80,,2623.43,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2548.01,percent of total billed charges,,,95,,3115.33,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3115.33,
ondansetron 2 mg/mL Inj Sol 2 mL [KHKS],6192474,CDM,636,RC,J2405,HCPCS,23155-0547-42,NDC,Outpatient,2,ML,2.5,,,,80,,2,percent of total billed charges,,,,50,0.06,fee schedule,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,0.06,2.38,
ondansetron 2 mg/mL Inj Sol 2 mL [KHKS],6192474,CDM,636,RC,J2405,HCPCS,23155-0547-42,NDC,Inpatient,2,ML,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
montelukast 10 mg Tab [KHKS],6192475,CDM,250,RC,68084-0875-01,NDC,,,Outpatient,1,EA,16.52,,,,80,,13.22,percent of total billed charges,,,,85,14.04,percent of total billed charges,,,77.7,,12.84,percent of total billed charges,,,95,,15.69,percent of total billed charges,,,60,,9.91,percent of total billed charges,,9.91,15.69,
montelukast 10 mg Tab [KHKS],6192475,CDM,250,RC,68084-0875-01,NDC,,,Inpatient,1,EA,16.52,,,,80,,13.22,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.84,percent of total billed charges,,,95,,15.69,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.69,
glucagon 1 mg Inj [KHKS],6192476,CDM,636,RC,J1610,HCPCS,00002-8031-01,NDC,Outpatient,1,EA,623.38,,,,80,,498.7,percent of total billed charges,,,,50,122.38,fee schedule,,,77.7,,484.36,percent of total billed charges,,,95,,592.21,percent of total billed charges,,,60,,374.03,percent of total billed charges,,122.38,592.21,
glucagon 1 mg Inj [KHKS],6192476,CDM,636,RC,J1610,HCPCS,00002-8031-01,NDC,Inpatient,1,EA,623.38,,,,80,,498.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,484.36,percent of total billed charges,,,95,,592.21,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,592.21,
cephalexin 125 mg/5 mL Oral Liq 100 mL [KHKS],6192478,CDM,250,RC,00093-4175-73,NDC,,,Outpatient,100,ML,71.25,,,,80,,57,percent of total billed charges,,,,85,60.56,percent of total billed charges,,,77.7,,55.36,percent of total billed charges,,,95,,67.69,percent of total billed charges,,,60,,42.75,percent of total billed charges,,42.75,67.69,
cephalexin 125 mg/5 mL Oral Liq 100 mL [KHKS],6192478,CDM,250,RC,00093-4175-73,NDC,,,Inpatient,100,ML,71.25,,,,80,,57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,55.36,percent of total billed charges,,,95,,67.69,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,67.69,
lisinopril 10 mg Tab [KHKS],6192480,CDM,250,RC,00904-6798-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
lisinopril 10 mg Tab [KHKS],6192480,CDM,250,RC,00904-6798-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
iodine-potassium iodide 5%-10% oral Sol 14 mL [KHKS],6192481,CDM,250,RC,48433-0230-15,NDC,,,Outpatient,14,ML,109.41,,,,80,,87.53,percent of total billed charges,,,,85,93,percent of total billed charges,,,77.7,,85.01,percent of total billed charges,,,95,,103.94,percent of total billed charges,,,60,,65.65,percent of total billed charges,,65.65,103.94,
iodine-potassium iodide 5%-10% oral Sol 14 mL [KHKS],6192481,CDM,250,RC,48433-0230-15,NDC,,,Inpatient,14,ML,109.41,,,,80,,87.53,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,85.01,percent of total billed charges,,,95,,103.94,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,103.94,
"zoster vaccine, inactivated adjuvanted Pow 0.5 mL [KHKS]",6192482,CDM,636,RC,90750,CPT,58160-0823-11,NDC,Outpatient,1,ML,380.88,,,,80,,304.71,percent of total billed charges,,,,50,130.96,fee schedule,,,77.7,,295.95,percent of total billed charges,,,95,,361.84,percent of total billed charges,,,60,,228.53,percent of total billed charges,,228.53,361.84,
"zoster vaccine, inactivated adjuvanted Pow 0.5 mL [KHKS]",6192482,CDM,636,RC,90750,CPT,58160-0823-11,NDC,Inpatient,1,ML,380.88,,,,80,,304.71,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,295.95,percent of total billed charges,,,95,,361.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,361.84,
prednisoLONE sodium phosphate 15 mg/5 mL Syringe Oral Liq (from 237 mL) [KHKS],6192483,CDM,250,RC,00121-0759-08,NDC,,,Outpatient,5,ML,4.68,,,,80,,3.75,percent of total billed charges,,,,85,3.98,percent of total billed charges,,,77.7,,3.64,percent of total billed charges,,,95,,4.45,percent of total billed charges,,,60,,2.81,percent of total billed charges,,2.81,4.45,
prednisoLONE sodium phosphate 15 mg/5 mL Syringe Oral Liq (from 237 mL) [KHKS],6192483,CDM,250,RC,00121-0759-08,NDC,,,Inpatient,5,ML,4.68,,,,80,,3.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.64,percent of total billed charges,,,95,,4.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.45,
Pediatric Multiple Vitamins Oral Liq 50 mL [KHKS],6192484,CDM,250,RC,00087-0402-03,NDC,,,Outpatient,50,ML,25.68,,,,80,,20.54,percent of total billed charges,,,,85,21.83,percent of total billed charges,,,77.7,,19.95,percent of total billed charges,,,95,,24.4,percent of total billed charges,,,60,,15.41,percent of total billed charges,,15.41,24.4,
Pediatric Multiple Vitamins Oral Liq 50 mL [KHKS],6192484,CDM,250,RC,00087-0402-03,NDC,,,Inpatient,50,ML,25.68,,,,80,,20.54,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.95,percent of total billed charges,,,95,,24.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,24.4,
regadenoson 0.4 mg/5 mL IV Sol [KHKS],6192485,CDM,636,RC,J2785,HCPCS,00469-6501-89,NDC,Outpatient,5,ML,555.56,,,,80,,444.44,percent of total billed charges,,,,50,39.56,fee schedule,,,77.7,,431.67,percent of total billed charges,,,95,,527.78,percent of total billed charges,,,60,,333.33,percent of total billed charges,,39.56,527.78,
regadenoson 0.4 mg/5 mL IV Sol [KHKS],6192485,CDM,636,RC,J2785,HCPCS,00469-6501-89,NDC,Inpatient,5,ML,555.56,,,,80,,444.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,431.67,percent of total billed charges,,,95,,527.78,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,527.78,
ibuprofen 200 mg Tab [KHKS],6192487,CDM,250,RC,00904-6747-59,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
ibuprofen 200 mg Tab [KHKS],6192487,CDM,250,RC,00904-6747-59,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
sterile water Inj Sol 10 mL Vial [KHKS],6192489,CDM,250,RC,63323-0185-10,NDC,,,Outpatient,10,ML,13.75,,,,80,,11,percent of total billed charges,,,,85,11.69,percent of total billed charges,,,77.7,,10.69,percent of total billed charges,,,95,,13.06,percent of total billed charges,,,60,,8.25,percent of total billed charges,,8.25,13.06,
sterile water Inj Sol 10 mL Vial [KHKS],6192489,CDM,250,RC,63323-0185-10,NDC,,,Inpatient,10,ML,13.75,,,,80,,11,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.69,percent of total billed charges,,,95,,13.06,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.06,
nitrofurantoin macrocrystals-monohydrate 100 mg Cap [KHKS],6192491,CDM,250,RC,68084-0446-01,NDC,,,Outpatient,1,EA,10.59,,,,80,,8.47,percent of total billed charges,,,,85,9,percent of total billed charges,,,77.7,,8.23,percent of total billed charges,,,95,,10.06,percent of total billed charges,,,60,,6.35,percent of total billed charges,,6.35,10.06,
nitrofurantoin macrocrystals-monohydrate 100 mg Cap [KHKS],6192491,CDM,250,RC,68084-0446-01,NDC,,,Inpatient,1,EA,10.59,,,,80,,8.47,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.23,percent of total billed charges,,,95,,10.06,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.06,
LORazepam 2 mg/mL Inj Sol 1 mL [KHKS],6192492,CDM,636,RC,J2060,HCPCS,00641-6044-25,NDC,Outpatient,1,ML,4.66,,,,80,,3.73,percent of total billed charges,,,,50,0.76,fee schedule,,,77.7,,3.62,percent of total billed charges,,,95,,4.43,percent of total billed charges,,,60,,2.8,percent of total billed charges,,0.76,4.43,
LORazepam 2 mg/mL Inj Sol 1 mL [KHKS],6192492,CDM,636,RC,J2060,HCPCS,00641-6044-25,NDC,Inpatient,1,ML,4.66,,,,80,,3.73,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.62,percent of total billed charges,,,95,,4.43,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.43,
morphine 30 mg/30mL INJ PCA Syringe [KHKS],6192493,CDM,636,RC,J2270,HCPCS,76329-1911-01,NDC,Outpatient,30,ML,43.2,,,,80,,34.56,percent of total billed charges,,,,50,2.15,fee schedule,,,77.7,,33.57,percent of total billed charges,,,95,,41.04,percent of total billed charges,,,60,,25.92,percent of total billed charges,,2.15,41.04,
morphine 30 mg/30mL INJ PCA Syringe [KHKS],6192493,CDM,636,RC,J2270,HCPCS,76329-1911-01,NDC,Inpatient,30,ML,43.2,,,,80,,34.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,33.57,percent of total billed charges,,,95,,41.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,41.04,
SUMAtriptan 6 mg/0.5 mL SQ Sol 0.5 mL[KHKS],6192495,CDM,636,RC,J3030,HCPCS,55150-0173-05,NDC,Outpatient,0.5,ML,255,,,,80,,204,percent of total billed charges,,,,50,30.98,fee schedule,,,77.7,,198.14,percent of total billed charges,,,95,,242.25,percent of total billed charges,,,60,,153,percent of total billed charges,,30.98,242.25,
SUMAtriptan 6 mg/0.5 mL SQ Sol 0.5 mL[KHKS],6192495,CDM,636,RC,J3030,HCPCS,55150-0173-05,NDC,Inpatient,0.5,ML,255,,,,80,,204,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,198.14,percent of total billed charges,,,95,,242.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,242.25,
dexamethasone 10 mg/mL PF Inj Sol 1 mL [KHKS],6192496,CDM,636,RC,J1100,HCPCS,70069-0021-25,NDC,Outpatient,1,ML,18.86,,,,80,,15.09,percent of total billed charges,,,,50,0.08,fee schedule,,,77.7,,14.66,percent of total billed charges,,,95,,17.92,percent of total billed charges,,,60,,11.32,percent of total billed charges,,0.08,17.92,
dexamethasone 10 mg/mL PF Inj Sol 1 mL [KHKS],6192496,CDM,636,RC,J1100,HCPCS,70069-0021-25,NDC,Inpatient,1,ML,18.86,,,,80,,15.09,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.66,percent of total billed charges,,,95,,17.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.92,
warfarin 5 mg Tab [KHKS],6192497,CDM,250,RC,62584-0994-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
warfarin 5 mg Tab [KHKS],6192497,CDM,250,RC,62584-0994-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
phenylephrine nasal 1% spray 15 mL [KHKS],6192498,CDM,250,RC,00225-0810-47,NDC,,,Outpatient,15,EA,13.2,,,,80,,10.56,percent of total billed charges,,,,85,11.22,percent of total billed charges,,,77.7,,10.26,percent of total billed charges,,,95,,12.54,percent of total billed charges,,,60,,7.92,percent of total billed charges,,7.92,12.54,
phenylephrine nasal 1% spray 15 mL [KHKS],6192498,CDM,250,RC,00225-0810-47,NDC,,,Inpatient,15,EA,13.2,,,,80,,10.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.26,percent of total billed charges,,,95,,12.54,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,12.54,
azithromycin 500. mg Powder-Inj,6192500,CDM,636,RC,J0456,HCPCS,55150-0174-10,NDC,Outpatient,1,EA,33,,,,80,,26.4,percent of total billed charges,,,,50,1.92,fee schedule,,,77.7,,25.64,percent of total billed charges,,,95,,31.35,percent of total billed charges,,,60,,19.8,percent of total billed charges,,1.92,31.35,
azithromycin 500. mg Powder-Inj,6192500,CDM,636,RC,J0456,HCPCS,55150-0174-10,NDC,Inpatient,1,EA,33,,,,80,,26.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,25.64,percent of total billed charges,,,95,,31.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,31.35,
cefdinir 300 mg Cap [KHKS],6192501,CDM,250,RC,16714-0391-02,NDC,,,Outpatient,1,EA,15.34,,,,80,,12.27,percent of total billed charges,,,,85,13.04,percent of total billed charges,,,77.7,,11.92,percent of total billed charges,,,95,,14.57,percent of total billed charges,,,60,,9.2,percent of total billed charges,,9.2,14.57,
cefdinir 300 mg Cap [KHKS],6192501,CDM,250,RC,16714-0391-02,NDC,,,Inpatient,1,EA,15.34,,,,80,,12.27,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.92,percent of total billed charges,,,95,,14.57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,14.57,
Sodium Chloride 0.9% with KCl 20 mEq/l IV PREMIX Sol 1000 mL [KHKS],6192502,CDM,636,RC,J3480,HCPCS,00990-7115-09,NDC,Outpatient,1000,ML,24.7,,,,80,,19.76,percent of total billed charges,,,,50,0.09,fee schedule,,,77.7,,19.19,percent of total billed charges,,,95,,23.46,percent of total billed charges,,,60,,14.82,percent of total billed charges,,0.09,23.46,
Sodium Chloride 0.9% with KCl 20 mEq/l IV PREMIX Sol 1000 mL [KHKS],6192502,CDM,636,RC,J3480,HCPCS,00990-7115-09,NDC,Inpatient,1000,ML,24.7,,,,80,,19.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.19,percent of total billed charges,,,95,,23.46,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,23.46,
famotidine 10 mg Tab [KHKS],6192503,CDM,250,RC,00904-5529-87,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
famotidine 10 mg Tab [KHKS],6192503,CDM,250,RC,00904-5529-87,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
furosemide 10 mg/mL Inj Sol 4 mL [KHKS],6192504,CDM,636,RC,J1940,HCPCS,70860-0302-04,NDC,Outpatient,4,ML,5.76,,,,80,,4.61,percent of total billed charges,,,,50,0.42,fee schedule,,,77.7,,4.48,percent of total billed charges,,,95,,5.47,percent of total billed charges,,,60,,3.46,percent of total billed charges,,0.42,5.47,
furosemide 10 mg/mL Inj Sol 4 mL [KHKS],6192504,CDM,636,RC,J1940,HCPCS,70860-0302-04,NDC,Inpatient,4,ML,5.76,,,,80,,4.61,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.48,percent of total billed charges,,,95,,5.47,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.47,
amoxicillin 500 mg Cap [KHKS],6192506,CDM,250,RC,16714-0299-03,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
amoxicillin 500 mg Cap [KHKS],6192506,CDM,250,RC,16714-0299-03,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
meperidine 25 mg/mL Inj Sol 1 mL [KHKS],6192507,CDM,636,RC,J2175,HCPCS,00641-6052-25,NDC,Outpatient,1,ML,9.13,,,,80,,7.3,percent of total billed charges,,,,50,6.17,fee schedule,,,77.7,,7.09,percent of total billed charges,,,95,,8.67,percent of total billed charges,,,60,,5.48,percent of total billed charges,,5.48,8.67,
meperidine 25 mg/mL Inj Sol 1 mL [KHKS],6192507,CDM,636,RC,J2175,HCPCS,00641-6052-25,NDC,Inpatient,1,ML,9.13,,,,80,,7.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.09,percent of total billed charges,,,95,,8.67,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,8.67,
medroxyPROGESTERone 150 mg/mL IM Susp [KHKS],6192508,CDM,636,RC,J1050,HCPCS,00548-5400-25,NDC,Outpatient,1,ML,162,,,,80,,129.6,percent of total billed charges,,,,50,0.25,fee schedule,,,77.7,,125.87,percent of total billed charges,,,95,,153.9,percent of total billed charges,,,60,,97.2,percent of total billed charges,,0.25,153.9,
medroxyPROGESTERone 150 mg/mL IM Susp [KHKS],6192508,CDM,636,RC,J1050,HCPCS,00548-5400-25,NDC,Inpatient,1,ML,162,,,,80,,129.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,125.87,percent of total billed charges,,,95,,153.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,153.9,
ePHEDrine 50 mg/mL Sol [KHKS],6192509,CDM,250,RC,17478-0955-10,NDC,,,Outpatient,1,ML,170.24,,,,80,,136.2,percent of total billed charges,,,,85,144.7,percent of total billed charges,,,77.7,,132.28,percent of total billed charges,,,95,,161.73,percent of total billed charges,,,60,,102.15,percent of total billed charges,,102.15,161.73,
ePHEDrine 50 mg/mL Sol [KHKS],6192509,CDM,250,RC,17478-0955-10,NDC,,,Inpatient,1,ML,170.24,,,,80,,136.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,132.28,percent of total billed charges,,,95,,161.73,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,161.73,
fluticasone Nasal 0.05 mg/inh Spry 16 gm[KHKS],6192510,CDM,250,RC,00054-3270-99,NDC,,,Outpatient,16,EA,225.81,,,,80,,180.65,percent of total billed charges,,,,85,191.94,percent of total billed charges,,,77.7,,175.45,percent of total billed charges,,,95,,214.52,percent of total billed charges,,,60,,135.49,percent of total billed charges,,135.49,214.52,
fluticasone Nasal 0.05 mg/inh Spry 16 gm[KHKS],6192510,CDM,250,RC,00054-3270-99,NDC,,,Inpatient,16,EA,225.81,,,,80,,180.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,175.45,percent of total billed charges,,,95,,214.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,214.52,
diltiazem 120 mg ER Cap [KHKS],6192511,CDM,250,RC,60687-0195-01,NDC,,,Outpatient,1,EA,2.9,,,,80,,2.32,percent of total billed charges,,,,85,2.47,percent of total billed charges,,,77.7,,2.25,percent of total billed charges,,,95,,2.75,percent of total billed charges,,,60,,1.74,percent of total billed charges,,1.74,2.75,
diltiazem 120 mg ER Cap [KHKS],6192511,CDM,250,RC,60687-0195-01,NDC,,,Inpatient,1,EA,2.9,,,,80,,2.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.25,percent of total billed charges,,,95,,2.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.75,
methadone 5 mg Tab [KHKS],6192512,CDM,250,RC,00406-5755-62,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
methadone 5 mg Tab [KHKS],6192512,CDM,250,RC,00406-5755-62,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
chlorhexidine Top 4% Soap 118 mL [KHKS],6192513,CDM,250,RC,00234-0575-04,NDC,,,Outpatient,118,EA,12.27,,,,80,,9.82,percent of total billed charges,,,,85,10.43,percent of total billed charges,,,77.7,,9.53,percent of total billed charges,,,95,,11.66,percent of total billed charges,,,60,,7.36,percent of total billed charges,,7.36,11.66,
chlorhexidine Top 4% Soap 118 mL [KHKS],6192513,CDM,250,RC,00234-0575-04,NDC,,,Inpatient,118,EA,12.27,,,,80,,9.82,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.53,percent of total billed charges,,,95,,11.66,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.66,
oxybutynin 5 mg Tab [KHKS],6192514,CDM,250,RC,00832-0038-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
oxybutynin 5 mg Tab [KHKS],6192514,CDM,250,RC,00832-0038-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
naloxone 1 mg/mL Inj Sol 2 mL [KHKS],6192515,CDM,636,RC,J2310,HCPCS,76329-3369-01,NDC,Outpatient,2,ML,118.8,,,,80,,95.04,percent of total billed charges,,,,50,6.62,fee schedule,,,77.7,,92.31,percent of total billed charges,,,95,,112.86,percent of total billed charges,,,60,,71.28,percent of total billed charges,,6.62,112.86,
naloxone 1 mg/mL Inj Sol 2 mL [KHKS],6192515,CDM,636,RC,J2310,HCPCS,76329-3369-01,NDC,Inpatient,2,ML,118.8,,,,80,,95.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,92.31,percent of total billed charges,,,95,,112.86,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,112.86,
sodium chloride 0.9% IRRIGATION Sol 500 mL [KHKS],6192516,CDM,250,RC,00990-6138-03,NDC,,,Outpatient,500,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,85,16.07,percent of total billed charges,,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,60,,11.34,percent of total billed charges,,11.34,17.96,
sodium chloride 0.9% IRRIGATION Sol 500 mL [KHKS],6192516,CDM,250,RC,00990-6138-03,NDC,,,Inpatient,500,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.96,
alteplase 100 mg IV Inj [KHKS],6192517,CDM,636,RC,J2997,HCPCS,50242-0085-27,NDC,Outpatient,1,EA,19536.8,,,,80,,15629.44,percent of total billed charges,,,,50,56.44,fee schedule,,,77.7,,15180.09,percent of total billed charges,,,95,,18559.96,percent of total billed charges,,,60,,11722.08,percent of total billed charges,,56.44,18559.96,
alteplase 100 mg IV Inj [KHKS],6192517,CDM,636,RC,J2997,HCPCS,50242-0085-27,NDC,Inpatient,1,EA,19536.8,,,,80,,15629.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,15180.09,percent of total billed charges,,,95,,18559.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,18559.96,
benztropine 1 mg Tab [KHKS],6192518,CDM,250,RC,60687-0368-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
benztropine 1 mg Tab [KHKS],6192518,CDM,250,RC,60687-0368-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
Dextrose 5% with NS IV Sol 1000 mL [KHKS],6192520,CDM,636,RC,J7042,HCPCS,00990-7941-09,NDC,Outpatient,1000,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,50,0.81,fee schedule,,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,60,,11.34,percent of total billed charges,,0.81,17.96,
Dextrose 5% with NS IV Sol 1000 mL [KHKS],6192520,CDM,636,RC,J7042,HCPCS,00990-7941-09,NDC,Inpatient,1000,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.96,
triamcinolone acetonide 40 mg/mL Inj Susp 1 mL [KHKS],6192521,CDM,636,RC,J3301,HCPCS,70121-1651-05,NDC,Outpatient,1,ML,30.6,,,,80,,24.48,percent of total billed charges,,,,50,0.68,fee schedule,,,77.7,,23.78,percent of total billed charges,,,95,,29.07,percent of total billed charges,,,60,,18.36,percent of total billed charges,,0.68,29.07,
triamcinolone acetonide 40 mg/mL Inj Susp 1 mL [KHKS],6192521,CDM,636,RC,J3301,HCPCS,70121-1651-05,NDC,Inpatient,1,ML,30.6,,,,80,,24.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,23.78,percent of total billed charges,,,95,,29.07,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,29.07,
lidocaine 2% 20 mg/mL PF Inj Sol 5 mL [KHKS],6192522,CDM,636,RC,J2003,HCPCS,63323-0495-07,NDC,Outpatient,5,ML,11.23,,,,80,,8.99,percent of total billed charges,,,,85,9.55,percent of total billed charges,,,77.7,,8.73,percent of total billed charges,,,95,,10.67,percent of total billed charges,,,60,,6.74,percent of total billed charges,,6.74,10.67,
lidocaine 2% 20 mg/mL PF Inj Sol 5 mL [KHKS],6192522,CDM,636,RC,J2003,HCPCS,63323-0495-07,NDC,Inpatient,5,ML,11.23,,,,80,,8.99,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.73,percent of total billed charges,,,95,,10.67,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.67,
mineral oil 100% Liquid,6192523,CDM,250,RC,48433-0202-30,NDC,,,Outpatient,30,ML,3.11,,,,80,,2.49,percent of total billed charges,,,,85,2.64,percent of total billed charges,,,77.7,,2.41,percent of total billed charges,,,95,,2.95,percent of total billed charges,,,60,,1.86,percent of total billed charges,,1.86,2.95,
mineral oil 100% Liquid,6192523,CDM,250,RC,48433-0202-30,NDC,,,Inpatient,30,ML,3.11,,,,80,,2.49,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.41,percent of total billed charges,,,95,,2.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.95,
sodium sulfacetamide Ophth 10% Sol 15 mL [KHKS],6192524,CDM,250,RC,24208-0670-04,NDC,,,Outpatient,15,EA,183,,,,80,,146.4,percent of total billed charges,,,,85,155.55,percent of total billed charges,,,77.7,,142.19,percent of total billed charges,,,95,,173.85,percent of total billed charges,,,60,,109.8,percent of total billed charges,,109.8,173.85,
sodium sulfacetamide Ophth 10% Sol 15 mL [KHKS],6192524,CDM,250,RC,24208-0670-04,NDC,,,Inpatient,15,EA,183,,,,80,,146.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,142.19,percent of total billed charges,,,95,,173.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,173.85,
benzocaine/butamben/tetracaine Top Spry 20 gm [KHKS],6192525,CDM,250,RC,10223-0201-03,NDC,,,Outpatient,20,EA,321.3,,,,80,,257.04,percent of total billed charges,,,,85,273.11,percent of total billed charges,,,77.7,,249.65,percent of total billed charges,,,95,,305.24,percent of total billed charges,,,60,,192.78,percent of total billed charges,,192.78,305.24,
benzocaine/butamben/tetracaine Top Spry 20 gm [KHKS],6192525,CDM,250,RC,10223-0201-03,NDC,,,Inpatient,20,EA,321.3,,,,80,,257.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,249.65,percent of total billed charges,,,95,,305.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,305.24,
enalapril 5 mg Tab [KHKS],6192526,CDM,250,RC,00904-5502-61,NDC,,,Outpatient,1,EA,4.63,,,,80,,3.71,percent of total billed charges,,,,85,3.94,percent of total billed charges,,,77.7,,3.6,percent of total billed charges,,,95,,4.4,percent of total billed charges,,,60,,2.78,percent of total billed charges,,2.78,4.4,
enalapril 5 mg Tab [KHKS],6192526,CDM,250,RC,00904-5502-61,NDC,,,Inpatient,1,EA,4.63,,,,80,,3.71,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.6,percent of total billed charges,,,95,,4.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.4,
amitriptyline 25 mg Tab [KHKS],6192528,CDM,250,RC,60687-0433-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
amitriptyline 25 mg Tab [KHKS],6192528,CDM,250,RC,60687-0433-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
doxycycline 100 mg IV Inj Sol [KHKS],6192529,CDM,250,RC,63323-0130-13,NDC,,,Outpatient,1,EA,86.98,,,,80,,69.58,percent of total billed charges,,,,85,73.93,percent of total billed charges,,,77.7,,67.58,percent of total billed charges,,,95,,82.63,percent of total billed charges,,,60,,52.19,percent of total billed charges,,52.19,82.63,
doxycycline 100 mg IV Inj Sol [KHKS],6192529,CDM,250,RC,63323-0130-13,NDC,,,Inpatient,1,EA,86.98,,,,80,,69.58,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,67.58,percent of total billed charges,,,95,,82.63,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,82.63,
scopolamine 1 mg/72 hr Patch [KHKS],6192530,CDM,250,RC,00591-2258-79,NDC,,,Outpatient,1,EA,72.83,,,,80,,58.26,percent of total billed charges,,,,85,61.91,percent of total billed charges,,,77.7,,56.59,percent of total billed charges,,,95,,69.19,percent of total billed charges,,,60,,43.7,percent of total billed charges,,43.7,69.19,
scopolamine 1 mg/72 hr Patch [KHKS],6192530,CDM,250,RC,00591-2258-79,NDC,,,Inpatient,1,EA,72.83,,,,80,,58.26,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,56.59,percent of total billed charges,,,95,,69.19,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,69.19,
procainamide 500 mg/mL Inj Sol 2 mL [KHKS],6192531,CDM,636,RC,J2690,HCPCS,14789-0900-02,NDC,Outpatient,2,ML,1332,,,,80,,1065.6,percent of total billed charges,,,,50,105.73,fee schedule,,,77.7,,1034.96,percent of total billed charges,,,95,,1265.4,percent of total billed charges,,,60,,799.2,percent of total billed charges,,105.73,1265.4,
procainamide 500 mg/mL Inj Sol 2 mL [KHKS],6192531,CDM,636,RC,J2690,HCPCS,14789-0900-02,NDC,Inpatient,2,ML,1332,,,,80,,1065.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1034.96,percent of total billed charges,,,95,,1265.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1265.4,
cloNIDine 0.1 mg Tab [KHKS],6192532,CDM,250,RC,00228-2127-10,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
cloNIDine 0.1 mg Tab [KHKS],6192532,CDM,250,RC,00228-2127-10,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
potassium chloride 10. mEq Tab-ER,6192533,CDM,250,RC,00245-5316-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
potassium chloride 10. mEq Tab-ER,6192533,CDM,250,RC,00245-5316-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
Sodium Chloride 0.9% with KCl 40 mEq/l IV PREMIX Sol 1000 mL [KHKS],6192534,CDM,636,RC,J3480,HCPCS,00990-7116-09,NDC,Outpatient,1000,ML,30.89,,,,80,,24.71,percent of total billed charges,,,,50,0.09,fee schedule,,,77.7,,24,percent of total billed charges,,,95,,29.34,percent of total billed charges,,,60,,18.53,percent of total billed charges,,0.09,29.34,
Sodium Chloride 0.9% with KCl 40 mEq/l IV PREMIX Sol 1000 mL [KHKS],6192534,CDM,636,RC,J3480,HCPCS,00990-7116-09,NDC,Inpatient,1000,ML,30.89,,,,80,,24.71,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,24,percent of total billed charges,,,95,,29.34,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,29.34,
liraglutide 18 mg/3 mL Sol Pen [KHKS],6192535,CDM,250,RC,00169-4060-12,NDC,,,Outpatient,3,ML,787.81,,,,80,,630.25,percent of total billed charges,,,,85,669.64,percent of total billed charges,,,77.7,,612.13,percent of total billed charges,,,95,,748.42,percent of total billed charges,,,60,,472.69,percent of total billed charges,,472.69,748.42,
liraglutide 18 mg/3 mL Sol Pen [KHKS],6192535,CDM,250,RC,00169-4060-12,NDC,,,Inpatient,3,ML,787.81,,,,80,,630.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,612.13,percent of total billed charges,,,95,,748.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,748.42,
nitroglycerin 0.4 mg sublingual Tab [KHKS],6192536,CDM,250,RC,68462-0639-45,NDC,,,Outpatient,1,EA,3.08,,,,80,,2.46,percent of total billed charges,,,,85,2.62,percent of total billed charges,,,77.7,,2.39,percent of total billed charges,,,95,,2.93,percent of total billed charges,,,60,,1.85,percent of total billed charges,,1.85,2.93,
nitroglycerin 0.4 mg sublingual Tab [KHKS],6192536,CDM,250,RC,68462-0639-45,NDC,,,Inpatient,1,EA,3.08,,,,80,,2.46,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.39,percent of total billed charges,,,95,,2.93,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.93,
misoprostol 100 mcg Tab [KHKS],6192538,CDM,250,RC,43386-0160-06,NDC,,,Outpatient,1,EA,2.94,,,,80,,2.35,percent of total billed charges,,,,85,2.5,percent of total billed charges,,,77.7,,2.28,percent of total billed charges,,,95,,2.79,percent of total billed charges,,,60,,1.76,percent of total billed charges,,1.76,2.79,
misoprostol 100 mcg Tab [KHKS],6192538,CDM,250,RC,43386-0160-06,NDC,,,Inpatient,1,EA,2.94,,,,80,,2.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.28,percent of total billed charges,,,95,,2.79,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.79,
cyclobenzaprine 10. mg Tab,6192539,CDM,250,RC,00093-3422-01,NDC,,,Outpatient,1,EA,3.45,,,,80,,2.76,percent of total billed charges,,,,85,2.93,percent of total billed charges,,,77.7,,2.68,percent of total billed charges,,,95,,3.27,percent of total billed charges,,,60,,2.07,percent of total billed charges,,2.07,3.27,
cyclobenzaprine 10. mg Tab,6192539,CDM,250,RC,00093-3422-01,NDC,,,Inpatient,1,EA,3.45,,,,80,,2.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.68,percent of total billed charges,,,95,,3.27,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.27,
Sodium Chloride 0.9% IV Sol 500 mL [KHKS],6192541,CDM,636,RC,J7040,HCPCS,00990-7983-03,NDC,Outpatient,500,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,50,0.83,fee schedule,,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,60,,11.34,percent of total billed charges,,0.83,17.96,
Sodium Chloride 0.9% IV Sol 500 mL [KHKS],6192541,CDM,636,RC,J7040,HCPCS,00990-7983-03,NDC,Inpatient,500,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.96,
famotidine 10 mg/mL IV Sol 2mL Vial [KHKS],6192542,CDM,250,RC,67457-0433-22,NDC,,,Outpatient,2,ML,3.2,,,,80,,2.56,percent of total billed charges,,,,85,2.72,percent of total billed charges,,,77.7,,2.49,percent of total billed charges,,,95,,3.04,percent of total billed charges,,,60,,1.92,percent of total billed charges,,1.92,3.04,
famotidine 10 mg/mL IV Sol 2mL Vial [KHKS],6192542,CDM,250,RC,67457-0433-22,NDC,,,Inpatient,2,ML,3.2,,,,80,,2.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.49,percent of total billed charges,,,95,,3.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.04,
zolpidem 5. mg Tab,6192543,CDM,250,RC,00904-6082-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
zolpidem 5. mg Tab,6192543,CDM,250,RC,00904-6082-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
Sodium Chloride 0.9% IV Sol 250 mL [KHKS],6192544,CDM,636,RC,J7050,HCPCS,00990-7983-02,NDC,Outpatient,250,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,50,0.51,fee schedule,,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,60,,11.34,percent of total billed charges,,0.51,17.96,
Sodium Chloride 0.9% IV Sol 250 mL [KHKS],6192544,CDM,636,RC,J7050,HCPCS,00990-7983-02,NDC,Inpatient,250,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.96,
amLODIPine 5 mg Tab [KHKS],6192546,CDM,250,RC,67877-0198-90,NDC,,,Outpatient,1,EA,5.37,,,,80,,4.29,percent of total billed charges,,,,85,4.56,percent of total billed charges,,,77.7,,4.17,percent of total billed charges,,,95,,5.1,percent of total billed charges,,,60,,3.22,percent of total billed charges,,3.22,5.1,
amLODIPine 5 mg Tab [KHKS],6192546,CDM,250,RC,67877-0198-90,NDC,,,Inpatient,1,EA,5.37,,,,80,,4.29,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.17,percent of total billed charges,,,95,,5.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.1,
SUMAtriptan 50 mg Oral Tab [KHKS],6192548,CDM,250,RC,55111-0292-98,NDC,,,Outpatient,1,EA,75.42,,,,80,,60.34,percent of total billed charges,,,,85,64.11,percent of total billed charges,,,77.7,,58.6,percent of total billed charges,,,95,,71.65,percent of total billed charges,,,60,,45.25,percent of total billed charges,,45.25,71.65,
SUMAtriptan 50 mg Oral Tab [KHKS],6192548,CDM,250,RC,55111-0292-98,NDC,,,Inpatient,1,EA,75.42,,,,80,,60.34,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,58.6,percent of total billed charges,,,95,,71.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,71.65,
FLUoxetine 10 mg Cap [KHKS],6192549,CDM,250,RC,00904-5784-61,NDC,,,Outpatient,1,EA,7.26,,,,80,,5.81,percent of total billed charges,,,,85,6.17,percent of total billed charges,,,77.7,,5.64,percent of total billed charges,,,95,,6.89,percent of total billed charges,,,60,,4.35,percent of total billed charges,,4.35,6.89,
FLUoxetine 10 mg Cap [KHKS],6192549,CDM,250,RC,00904-5784-61,NDC,,,Inpatient,1,EA,7.26,,,,80,,5.81,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.64,percent of total billed charges,,,95,,6.89,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.89,
sodium chloride 0.9% IRRIGICATION Sol 1000 mL [KHKS],6192550,CDM,250,RC,00990-7138-09,NDC,,,Outpatient,1000,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,85,16.07,percent of total billed charges,,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,60,,11.34,percent of total billed charges,,11.34,17.96,
sodium chloride 0.9% IRRIGICATION Sol 1000 mL [KHKS],6192550,CDM,250,RC,00990-7138-09,NDC,,,Inpatient,1000,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.96,
azithromycin 100 mg/5 mL Oral Liq 15 mL [KHKS],6192551,CDM,250,RC,70710-1457-01,NDC,,,Outpatient,15,ML,104.64,,,,80,,83.71,percent of total billed charges,,,,85,88.94,percent of total billed charges,,,77.7,,81.31,percent of total billed charges,,,95,,99.41,percent of total billed charges,,,60,,62.78,percent of total billed charges,,62.78,99.41,
azithromycin 100 mg/5 mL Oral Liq 15 mL [KHKS],6192551,CDM,250,RC,70710-1457-01,NDC,,,Inpatient,15,ML,104.64,,,,80,,83.71,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,81.31,percent of total billed charges,,,95,,99.41,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,99.41,
potassium phosphate-sodium phosphate 250 mg-45 mg-298 mg Tab,6192552,CDM,250,RC,64980-0104-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
potassium phosphate-sodium phosphate 250 mg-45 mg-298 mg Tab,6192552,CDM,250,RC,64980-0104-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
lisinopril 5 mg Tab [KHKS],6192553,CDM,250,RC,00904-6797-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
lisinopril 5 mg Tab [KHKS],6192553,CDM,250,RC,00904-6797-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
mirtazapine 15 mg Tab [KHKS],6192554,CDM,250,RC,00904-6519-61,NDC,,,Outpatient,1,EA,8.58,,,,80,,6.86,percent of total billed charges,,,,85,7.29,percent of total billed charges,,,77.7,,6.66,percent of total billed charges,,,95,,8.15,percent of total billed charges,,,60,,5.15,percent of total billed charges,,5.15,8.15,
mirtazapine 15 mg Tab [KHKS],6192554,CDM,250,RC,00904-6519-61,NDC,,,Inpatient,1,EA,8.58,,,,80,,6.86,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.66,percent of total billed charges,,,95,,8.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,8.15,
fentaNYL 12 mcg/hr Patch [KHKS],6192555,CDM,250,RC,60505-7080-02,NDC,,,Outpatient,1,EA,60.91,,,,80,,48.72,percent of total billed charges,,,,85,51.77,percent of total billed charges,,,77.7,,47.32,percent of total billed charges,,,95,,57.86,percent of total billed charges,,,60,,36.54,percent of total billed charges,,36.54,57.86,
fentaNYL 12 mcg/hr Patch [KHKS],6192555,CDM,250,RC,60505-7080-02,NDC,,,Inpatient,1,EA,60.91,,,,80,,48.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,47.32,percent of total billed charges,,,95,,57.86,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,57.86,
cefTRIAXone 500 mg Inj vial [KHKS],6192556,CDM,636,RC,J0696,HCPCS,00409-7338-20,NDC,Outpatient,1,EA,3.47,,,,80,,2.78,percent of total billed charges,,,,50,0.4,fee schedule,,,77.7,,2.7,percent of total billed charges,,,95,,3.3,percent of total billed charges,,,60,,2.08,percent of total billed charges,,0.4,3.3,
cefTRIAXone 500 mg Inj vial [KHKS],6192556,CDM,636,RC,J0696,HCPCS,00409-7338-20,NDC,Inpatient,1,EA,3.47,,,,80,,2.78,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.7,percent of total billed charges,,,95,,3.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.3,
mannitol 25% IV Sol 50 mL [KHKS],6192557,CDM,636,RC,J2150,HCPCS,63323-0024-25,NDC,Outpatient,50,ML,17.5,,,,80,,14,percent of total billed charges,,,,50,3.2,fee schedule,,,77.7,,13.59,percent of total billed charges,,,95,,16.62,percent of total billed charges,,,60,,10.5,percent of total billed charges,,3.2,16.62,
mannitol 25% IV Sol 50 mL [KHKS],6192557,CDM,636,RC,J2150,HCPCS,63323-0024-25,NDC,Inpatient,50,ML,17.5,,,,80,,14,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,13.59,percent of total billed charges,,,95,,16.62,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,16.62,
nicotine 21 mg/24 hr Patch [KHKS],6192558,CDM,250,RC,43598-0448-74,NDC,,,Outpatient,1,EA,6.4,,,,80,,5.12,percent of total billed charges,,,,85,5.44,percent of total billed charges,,,77.7,,4.97,percent of total billed charges,,,95,,6.08,percent of total billed charges,,,60,,3.84,percent of total billed charges,,3.84,6.08,
nicotine 21 mg/24 hr Patch [KHKS],6192558,CDM,250,RC,43598-0448-74,NDC,,,Inpatient,1,EA,6.4,,,,80,,5.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.97,percent of total billed charges,,,95,,6.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.08,
hydrALAZINE 25 mg Tab [KHKS],6192559,CDM,250,RC,62584-0733-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
hydrALAZINE 25 mg Tab [KHKS],6192559,CDM,250,RC,62584-0733-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
oseltamivir 75 mg Cap [KHKS],6192560,CDM,250,RC,31722-0632-31,NDC,,,Outpatient,1,EA,46.37,,,,80,,37.1,percent of total billed charges,,,,85,39.41,percent of total billed charges,,,77.7,,36.03,percent of total billed charges,,,95,,44.05,percent of total billed charges,,,60,,27.82,percent of total billed charges,,27.82,44.05,
oseltamivir 75 mg Cap [KHKS],6192560,CDM,250,RC,31722-0632-31,NDC,,,Inpatient,1,EA,46.37,,,,80,,37.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,36.03,percent of total billed charges,,,95,,44.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,44.05,
levETIRAcetam 100 mg/mL IV Sol [KHKS],6192561,CDM,636,RC,J1953,HCPCS,55150-0177-05,NDC,Outpatient,5,ML,45,,,,80,,36,percent of total billed charges,,,,50,0.06,fee schedule,,,77.7,,34.97,percent of total billed charges,,,95,,42.75,percent of total billed charges,,,60,,27,percent of total billed charges,,0.06,42.75,
levETIRAcetam 100 mg/mL IV Sol [KHKS],6192561,CDM,636,RC,J1953,HCPCS,55150-0177-05,NDC,Inpatient,5,ML,45,,,,80,,36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,34.97,percent of total billed charges,,,95,,42.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,42.75,
fluticasone CFC free 220 mcg/inh Inh Aer w/adap 12 gm [KHKS],6192562,CDM,250,RC,00173-0720-20,NDC,,,Outpatient,12,EA,944.24,,,,80,,755.39,percent of total billed charges,,,,85,802.6,percent of total billed charges,,,77.7,,733.67,percent of total billed charges,,,95,,897.03,percent of total billed charges,,,60,,566.54,percent of total billed charges,,566.54,897.03,
fluticasone CFC free 220 mcg/inh Inh Aer w/adap 12 gm [KHKS],6192562,CDM,250,RC,00173-0720-20,NDC,,,Inpatient,12,EA,944.24,,,,80,,755.39,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,733.67,percent of total billed charges,,,95,,897.03,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,897.03,
ropivacaine 0.5% (5 mg/mL) Inj Sol 30 mL [KHKS],6192563,CDM,636,RC,J2795,HCPCS,63323-0286-95,NDC,Outpatient,30,ML,101.59,,,,80,,81.27,percent of total billed charges,,,,50,0.06,fee schedule,,,77.7,,78.94,percent of total billed charges,,,95,,96.51,percent of total billed charges,,,60,,60.96,percent of total billed charges,,0.06,96.51,
ropivacaine 0.5% (5 mg/mL) Inj Sol 30 mL [KHKS],6192563,CDM,636,RC,J2795,HCPCS,63323-0286-95,NDC,Inpatient,30,ML,101.59,,,,80,,81.27,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,78.94,percent of total billed charges,,,95,,96.51,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,96.51,
gabapentin 300 mg Cap [KHKS],6192564,CDM,250,RC,63739-0903-10,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
gabapentin 300 mg Cap [KHKS],6192564,CDM,250,RC,63739-0903-10,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
levETIRAcetam 500. mg Tab,6192565,CDM,250,RC,63739-0411-10,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
levETIRAcetam 500. mg Tab,6192565,CDM,250,RC,63739-0411-10,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
bupivacaine 0.75% intrathecal Sol 2 mL [KHKS],6192566,CDM,250,RC,00409-1761-10,NDC,,,Outpatient,2,ML,16.32,,,,80,,13.05,percent of total billed charges,,,,85,13.87,percent of total billed charges,,,77.7,,12.68,percent of total billed charges,,,95,,15.5,percent of total billed charges,,,60,,9.79,percent of total billed charges,,9.79,15.5,
bupivacaine 0.75% intrathecal Sol 2 mL [KHKS],6192566,CDM,250,RC,00409-1761-10,NDC,,,Inpatient,2,ML,16.32,,,,80,,13.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.68,percent of total billed charges,,,95,,15.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.5,
neostigmine 1 mg/mL Sol 10 mL [KHKS],6192567,CDM,636,RC,J2710,HCPCS,63323-0415-10,NDC,Outpatient,10,ML,100.8,,,,80,,80.64,percent of total billed charges,,,,50,0.76,fee schedule,,,77.7,,78.32,percent of total billed charges,,,95,,95.76,percent of total billed charges,,,60,,60.48,percent of total billed charges,,0.76,95.76,
neostigmine 1 mg/mL Sol 10 mL [KHKS],6192567,CDM,636,RC,J2710,HCPCS,63323-0415-10,NDC,Inpatient,10,ML,100.8,,,,80,,80.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,78.32,percent of total billed charges,,,95,,95.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,95.76,
ciprofloxacin 500. mg Tab,6192568,CDM,250,RC,00904-7083-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
ciprofloxacin 500. mg Tab,6192568,CDM,250,RC,00904-7083-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
potassium phosphate 3 mmol/mL IV Sol 15 mL [KHKS],6192569,CDM,250,RC,00409-7295-01,NDC,,,Outpatient,1,ML,3.55,,,,80,,2.84,percent of total billed charges,,,,85,3.02,percent of total billed charges,,,77.7,,2.76,percent of total billed charges,,,95,,3.37,percent of total billed charges,,,60,,2.13,percent of total billed charges,,2.13,3.37,
potassium phosphate 3 mmol/mL IV Sol 15 mL [KHKS],6192569,CDM,250,RC,00409-7295-01,NDC,,,Inpatient,1,ML,3.55,,,,80,,2.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.76,percent of total billed charges,,,95,,3.37,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.37,
codeine-guaiFENesin 10 mg-100 mg/5 mL Oral Syrup 10 mL [KHKS],6192570,CDM,250,RC,00121-1550-00,NDC,,,Outpatient,10,ML,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
codeine-guaiFENesin 10 mg-100 mg/5 mL Oral Syrup 10 mL [KHKS],6192570,CDM,250,RC,00121-1550-00,NDC,,,Inpatient,10,ML,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
phytonadione 1 mg/0.5 mL Inj Sol 0.5 mL [KHKS],6192571,CDM,636,RC,J3430,HCPCS,00409-9157-01,NDC,Outpatient,0.5,ML,17.08,,,,80,,13.67,percent of total billed charges,,,,50,2.05,fee schedule,,,77.7,,13.27,percent of total billed charges,,,95,,16.23,percent of total billed charges,,,60,,10.25,percent of total billed charges,,2.05,16.23,
phytonadione 1 mg/0.5 mL Inj Sol 0.5 mL [KHKS],6192571,CDM,636,RC,J3430,HCPCS,00409-9157-01,NDC,Inpatient,0.5,ML,17.08,,,,80,,13.67,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,13.27,percent of total billed charges,,,95,,16.23,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,16.23,
bupivacaine 0.75% intrathecal Sol 2 mL [KHKS],6192572,CDM,636,RC,J0665,HCPCS,00409-3613-01,NDC,Outpatient,2,ML,8.48,,,,80,,6.78,percent of total billed charges,,,,85,7.21,percent of total billed charges,,,77.7,,6.59,percent of total billed charges,,,95,,8.05,percent of total billed charges,,,60,,5.09,percent of total billed charges,,5.09,8.05,
bupivacaine 0.75% intrathecal Sol 2 mL [KHKS],6192572,CDM,636,RC,J0665,HCPCS,00409-3613-01,NDC,Inpatient,2,ML,8.48,,,,80,,6.78,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.59,percent of total billed charges,,,95,,8.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,8.05,
DOPamine 400 mg/250 mL D5W 250 mL [KHKS],6192573,CDM,636,RC,J1265,HCPCS,00409-7809-22,NDC,Outpatient,250,ML,47.32,,,,80,,37.86,percent of total billed charges,,,,50,0.43,fee schedule,,,77.7,,36.77,percent of total billed charges,,,95,,44.96,percent of total billed charges,,,60,,28.39,percent of total billed charges,,0.43,44.96,
DOPamine 400 mg/250 mL D5W 250 mL [KHKS],6192573,CDM,636,RC,J1265,HCPCS,00409-7809-22,NDC,Inpatient,250,ML,47.32,,,,80,,37.86,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,36.77,percent of total billed charges,,,95,,44.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,44.96,
lidocaine 2% 20 mg/mL Inj Sol 10 mL [KHKS],6192575,CDM,636,RC,J2003,HCPCS,63323-0486-10,NDC,Outpatient,10,ML,9,,,,80,,7.2,percent of total billed charges,,,,85,7.65,percent of total billed charges,,,77.7,,6.99,percent of total billed charges,,,95,,8.55,percent of total billed charges,,,60,,5.4,percent of total billed charges,,5.4,8.55,
lidocaine 2% 20 mg/mL Inj Sol 10 mL [KHKS],6192575,CDM,636,RC,J2003,HCPCS,63323-0486-10,NDC,Inpatient,10,ML,9,,,,80,,7.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.99,percent of total billed charges,,,95,,8.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,8.55,
acetaminophen 10 mg/mL Sol 100 mL Vial [KHKS],6192576,CDM,636,RC,J0131,HCPCS,24201-0100-24,NDC,Outpatient,100,ML,127.9,,,,80,,102.32,percent of total billed charges,,,,50,0.06,fee schedule,,,77.7,,99.38,percent of total billed charges,,,95,,121.51,percent of total billed charges,,,60,,76.74,percent of total billed charges,,0.06,121.51,
acetaminophen 10 mg/mL Sol 100 mL Vial [KHKS],6192576,CDM,636,RC,J0131,HCPCS,24201-0100-24,NDC,Inpatient,100,ML,127.9,,,,80,,102.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,99.38,percent of total billed charges,,,95,,121.51,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,121.51,
fluconazole 200 mg/100 mL-NS PREMIX IV Sol [KHKS],6192577,CDM,636,RC,J1450,HCPCS,00409-4688-28,NDC,Outpatient,100,ML,42.31,,,,80,,33.85,percent of total billed charges,,,,50,1.5,fee schedule,,,77.7,,32.88,percent of total billed charges,,,95,,40.2,percent of total billed charges,,,60,,25.39,percent of total billed charges,,1.5,40.2,
fluconazole 200 mg/100 mL-NS PREMIX IV Sol [KHKS],6192577,CDM,636,RC,J1450,HCPCS,00409-4688-28,NDC,Inpatient,100,ML,42.31,,,,80,,33.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,32.88,percent of total billed charges,,,95,,40.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,40.2,
glucose 50% IV Sol 50 mL [KHKS],6192578,CDM,250,RC,00409-7517-16,NDC,,,Outpatient,50,ML,40.08,,,,80,,32.07,percent of total billed charges,,,,85,34.07,percent of total billed charges,,,77.7,,31.14,percent of total billed charges,,,95,,38.08,percent of total billed charges,,,60,,24.05,percent of total billed charges,,24.05,38.08,
glucose 50% IV Sol 50 mL [KHKS],6192578,CDM,250,RC,00409-7517-16,NDC,,,Inpatient,50,ML,40.08,,,,80,,32.07,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,31.14,percent of total billed charges,,,95,,38.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,38.08,
sodium bicarbonate 4.2% IV Sol 10 mL [KHKS],6192580,CDM,250,RC,00409-5534-14,NDC,,,Outpatient,10,ML,49.45,,,,80,,39.56,percent of total billed charges,,,,85,42.03,percent of total billed charges,,,77.7,,38.42,percent of total billed charges,,,95,,46.97,percent of total billed charges,,,60,,29.67,percent of total billed charges,,29.67,46.97,
sodium bicarbonate 4.2% IV Sol 10 mL [KHKS],6192580,CDM,250,RC,00409-5534-14,NDC,,,Inpatient,10,ML,49.45,,,,80,,39.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,38.42,percent of total billed charges,,,95,,46.97,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,46.97,
lactulose 10 g/15 mL Oral Syrup [KHKS],6192582,CDM,250,RC,00121-1154-00,NDC,,,Outpatient,30,ML,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
lactulose 10 g/15 mL Oral Syrup [KHKS],6192582,CDM,250,RC,00121-1154-00,NDC,,,Inpatient,30,ML,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
acetaminophen 325 mg Supp [KHKS],6192583,CDM,250,RC,51672-2116-04,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
acetaminophen 325 mg Supp [KHKS],6192583,CDM,250,RC,51672-2116-04,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
lidocaine 1% Inj Sol 50 mL [KHKS],6192584,CDM,250,RC,00143-9577-10,NDC,,,Outpatient,50,ML,10.04,,,,80,,8.04,percent of total billed charges,,,,85,8.53,percent of total billed charges,,,77.7,,7.8,percent of total billed charges,,,95,,9.54,percent of total billed charges,,,60,,6.03,percent of total billed charges,,6.03,9.54,
lidocaine 1% Inj Sol 50 mL [KHKS],6192584,CDM,250,RC,00143-9577-10,NDC,,,Inpatient,50,ML,10.04,,,,80,,8.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.8,percent of total billed charges,,,95,,9.54,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.54,
THP AMOXICILLIN (Amoxil) 400 MG/5ML SUSP 75ML [KHKS],6192670,CDM,253,RC,00143-9887-75QQ,NDC,,,Outpatient,1,EA,8.89,,,,80,,7.11,percent of total billed charges,,,,85,7.56,percent of total billed charges,,,77.7,,6.91,percent of total billed charges,,,95,,8.45,percent of total billed charges,,,60,,5.33,percent of total billed charges,,5.33,8.45,
THP AMOXICILLIN (Amoxil) 400 MG/5ML SUSP 75ML [KHKS],6192670,CDM,253,RC,00143-9887-75QQ,NDC,,,Inpatient,1,EA,8.89,,,,80,,7.11,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.91,percent of total billed charges,,,95,,8.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,8.45,
THP TRAMADOL (Ultram) 50 MG TAB  #4 [KHKS],6192676,CDM,253,RC,51079-0991-20QQ,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
THP TRAMADOL (Ultram) 50 MG TAB  #4 [KHKS],6192676,CDM,253,RC,51079-0991-20QQ,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
THP SULFAMETH/TMP 200/40/5mL (Bactrim) LIQUID 60mL  [KHKS],6192679,CDM,253,RC,65862-0496-47QQ,NDC,,,Outpatient,1,EA,6.21,,,,80,,4.97,percent of total billed charges,,,,85,5.28,percent of total billed charges,,,77.7,,4.83,percent of total billed charges,,,95,,5.9,percent of total billed charges,,,60,,3.73,percent of total billed charges,,3.73,5.9,
THP SULFAMETH/TMP 200/40/5mL (Bactrim) LIQUID 60mL  [KHKS],6192679,CDM,253,RC,65862-0496-47QQ,NDC,,,Inpatient,1,EA,6.21,,,,80,,4.97,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.83,percent of total billed charges,,,95,,5.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.9,
THP SULFAM/TRIMETH (Bactrim) 800-160 TAB #4 [KHKS],6192681,CDM,253,RC,00904-2725-61QQ,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
THP SULFAM/TRIMETH (Bactrim) 800-160 TAB #4 [KHKS],6192681,CDM,253,RC,00904-2725-61QQ,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
THP ALBUTEROL 0.083% 2.5 MG/3 ML SOL (Proventil) #5 [KHKS],6192682,CDM,253,RC,76204-0200-60QQ,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
THP ALBUTEROL 0.083% 2.5 MG/3 ML SOL (Proventil) #5 [KHKS],6192682,CDM,253,RC,76204-0200-60QQ,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
THP ALBUTEROL 90 MCG INH (Ventolin) 8 GM [KHKS],6192683,CDM,253,RC,00173-0682-24QQ,NDC,,,Outpatient,1,EA,5.11,,,,80,,4.09,percent of total billed charges,,,,85,4.34,percent of total billed charges,,,77.7,,3.97,percent of total billed charges,,,95,,4.85,percent of total billed charges,,,60,,3.07,percent of total billed charges,,3.07,4.85,
THP ALBUTEROL 90 MCG INH (Ventolin) 8 GM [KHKS],6192683,CDM,253,RC,00173-0682-24QQ,NDC,,,Inpatient,1,EA,5.11,,,,80,,4.09,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.97,percent of total billed charges,,,95,,4.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.85,
THP AMOXICILLIN (Amoxil) 400 MG/5 ML SUSP 50ML [KHKS],6192687,CDM,253,RC,65862-0071-50QQ,NDC,,,Outpatient,1,EA,3.66,,,,80,,2.93,percent of total billed charges,,,,85,3.11,percent of total billed charges,,,77.7,,2.84,percent of total billed charges,,,95,,3.47,percent of total billed charges,,,60,,2.19,percent of total billed charges,,2.19,3.47,
THP AMOXICILLIN (Amoxil) 400 MG/5 ML SUSP 50ML [KHKS],6192687,CDM,253,RC,65862-0071-50QQ,NDC,,,Inpatient,1,EA,3.66,,,,80,,2.93,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.84,percent of total billed charges,,,95,,3.47,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.47,
THP PROMETHAZINE (Phenergan) 25 MG TAB #4 [KHKS],6192688,CDM,253,RC,63739-0213-10QQ,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
THP PROMETHAZINE (Phenergan) 25 MG TAB #4 [KHKS],6192688,CDM,253,RC,63739-0213-10QQ,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
THP AMOXICILLIN (Amoxil) 500 MG CAP #4 [KHKS],6192690,CDM,253,RC,16714-0299-03QQ,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
THP AMOXICILLIN (Amoxil) 500 MG CAP #4 [KHKS],6192690,CDM,253,RC,16714-0299-03QQ,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
THP PREDNISONE 10 MG TAB #8 [KHKS],6192691,CDM,253,RC,00054-0017-20QQ,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
THP PREDNISONE 10 MG TAB #8 [KHKS],6192691,CDM,253,RC,00054-0017-20QQ,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
THP AMOXICILLIN-CLAVULANATE (Augmentin) 400 MG/5 ML SUSP 100 ML [KHKS],6192693,CDM,253,RC,16714-0478-02QQ,NDC,,,Outpatient,1,EA,21.74,,,,80,,17.39,percent of total billed charges,,,,85,18.48,percent of total billed charges,,,77.7,,16.89,percent of total billed charges,,,95,,20.65,percent of total billed charges,,,60,,13.04,percent of total billed charges,,13.04,20.65,
THP AMOXICILLIN-CLAVULANATE (Augmentin) 400 MG/5 ML SUSP 100 ML [KHKS],6192693,CDM,253,RC,16714-0478-02QQ,NDC,,,Inpatient,1,EA,21.74,,,,80,,17.39,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,16.89,percent of total billed charges,,,95,,20.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,20.65,
THP PREDNISOLONE (Orapred) 15 MG/5 ML ORAL LIQ 30ML  [KHKS],6192694,CDM,253,RC,00121-0759-08QQ,NDC,,,Outpatient,1,EA,5.76,,,,80,,4.61,percent of total billed charges,,,,85,4.9,percent of total billed charges,,,77.7,,4.47,percent of total billed charges,,,95,,5.47,percent of total billed charges,,,60,,3.45,percent of total billed charges,,3.45,5.47,
THP PREDNISOLONE (Orapred) 15 MG/5 ML ORAL LIQ 30ML  [KHKS],6192694,CDM,253,RC,00121-0759-08QQ,NDC,,,Inpatient,1,EA,5.76,,,,80,,4.61,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.47,percent of total billed charges,,,95,,5.47,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.47,
THP AZITHROMYCIN (Zithromax) 100 MG/5 ML SUSP 15 ML [KHKS],6192695,CDM,253,RC,70710-1457-01QQ,NDC,,,Outpatient,1,EA,15.89,,,,80,,12.71,percent of total billed charges,,,,85,13.51,percent of total billed charges,,,77.7,,12.35,percent of total billed charges,,,95,,15.1,percent of total billed charges,,,60,,9.53,percent of total billed charges,,9.53,15.1,
THP AZITHROMYCIN (Zithromax) 100 MG/5 ML SUSP 15 ML [KHKS],6192695,CDM,253,RC,70710-1457-01QQ,NDC,,,Inpatient,1,EA,15.89,,,,80,,12.71,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.35,percent of total billed charges,,,95,,15.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.1,
THP OXYCODONE/APAP (Percocet) 5-325 #4 [KHKS],6192696,CDM,253,RC,00406-0512-62QQ,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
THP OXYCODONE/APAP (Percocet) 5-325 #4 [KHKS],6192696,CDM,253,RC,00406-0512-62QQ,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
THP AZITHROMYCIN (Zithromax) 200 MG/5 ML SUSP 15 ML [KHKS],6192698,CDM,253,RC,59762-3120-01QQ,NDC,,,Outpatient,1,EA,16.1,,,,80,,12.88,percent of total billed charges,,,,85,13.69,percent of total billed charges,,,77.7,,12.51,percent of total billed charges,,,95,,15.3,percent of total billed charges,,,60,,9.66,percent of total billed charges,,9.66,15.3,
THP AZITHROMYCIN (Zithromax) 200 MG/5 ML SUSP 15 ML [KHKS],6192698,CDM,253,RC,59762-3120-01QQ,NDC,,,Inpatient,1,EA,16.1,,,,80,,12.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.51,percent of total billed charges,,,95,,15.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.3,
THP OSELTAMIVIR (Tamiflu) 75MG CAP #2 [KHKS],6192699,CDM,253,RC,16714-0819-01QQ,NDC,,,Outpatient,1,EA,5.25,,,,80,,4.2,percent of total billed charges,,,,85,4.46,percent of total billed charges,,,77.7,,4.08,percent of total billed charges,,,95,,4.99,percent of total billed charges,,,60,,3.15,percent of total billed charges,,3.15,4.99,
THP OSELTAMIVIR (Tamiflu) 75MG CAP #2 [KHKS],6192699,CDM,253,RC,16714-0819-01QQ,NDC,,,Inpatient,1,EA,5.25,,,,80,,4.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.08,percent of total billed charges,,,95,,4.99,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.99,
THP AZITHROMYCIN (Zithromax) 250 MG TAB #4 [KHKS],6192702,CDM,253,RC,00904-6708-06QQ,NDC,,,Outpatient,1,EA,3.41,,,,80,,2.73,percent of total billed charges,,,,85,2.9,percent of total billed charges,,,77.7,,2.65,percent of total billed charges,,,95,,3.24,percent of total billed charges,,,60,,2.05,percent of total billed charges,,2.05,3.24,
THP AZITHROMYCIN (Zithromax) 250 MG TAB #4 [KHKS],6192702,CDM,253,RC,00904-6708-06QQ,NDC,,,Inpatient,1,EA,3.41,,,,80,,2.73,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.65,percent of total billed charges,,,95,,3.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.24,
THP CEFDINIR (Omnicef) 125 MG/5 ML SUSP 60 ML [KHKS],6192707,CDM,253,RC,16714-0392-01QQ,NDC,,,Outpatient,1,EA,51.7,,,,80,,41.36,percent of total billed charges,,,,85,43.95,percent of total billed charges,,,77.7,,40.17,percent of total billed charges,,,95,,49.11,percent of total billed charges,,,60,,31.02,percent of total billed charges,,31.02,49.11,
THP CEFDINIR (Omnicef) 125 MG/5 ML SUSP 60 ML [KHKS],6192707,CDM,253,RC,16714-0392-01QQ,NDC,,,Inpatient,1,EA,51.7,,,,80,,41.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,40.17,percent of total billed charges,,,95,,49.11,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,49.11,
THP CEFDINIR (Omnicef) 300 MG CAP #4 [KHKS],6192729,CDM,253,RC,16714-0391-02QQ,NDC,,,Outpatient,1,EA,11.2,,,,80,,8.96,percent of total billed charges,,,,85,9.52,percent of total billed charges,,,77.7,,8.7,percent of total billed charges,,,95,,10.64,percent of total billed charges,,,60,,6.72,percent of total billed charges,,6.72,10.64,
THP CEFDINIR (Omnicef) 300 MG CAP #4 [KHKS],6192729,CDM,253,RC,16714-0391-02QQ,NDC,,,Inpatient,1,EA,11.2,,,,80,,8.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.7,percent of total billed charges,,,95,,10.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.64,
THP CEPHALEXIN (Keflex) 250 MG/5 ML SUSP 100 ML [KHKS],6192731,CDM,253,RC,68180-0440-01QQ,NDC,,,Outpatient,1,EA,34.55,,,,80,,27.64,percent of total billed charges,,,,85,29.37,percent of total billed charges,,,77.7,,26.84,percent of total billed charges,,,95,,32.82,percent of total billed charges,,,60,,20.73,percent of total billed charges,,20.73,32.82,
THP CEPHALEXIN (Keflex) 250 MG/5 ML SUSP 100 ML [KHKS],6192731,CDM,253,RC,68180-0440-01QQ,NDC,,,Inpatient,1,EA,34.55,,,,80,,27.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,26.84,percent of total billed charges,,,95,,32.82,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,32.82,
THP OSELTAMIVIR (Tamiflu) 6MG/ML SUSP 60ML [KHKS],6192732,CDM,253,RC,68180-0678-01QQ,NDC,,,Outpatient,1,EA,115.41,,,,80,,92.33,percent of total billed charges,,,,85,98.1,percent of total billed charges,,,77.7,,89.68,percent of total billed charges,,,95,,109.64,percent of total billed charges,,,60,,69.25,percent of total billed charges,,69.25,109.64,
THP OSELTAMIVIR (Tamiflu) 6MG/ML SUSP 60ML [KHKS],6192732,CDM,253,RC,68180-0678-01QQ,NDC,,,Inpatient,1,EA,115.41,,,,80,,92.33,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,89.68,percent of total billed charges,,,95,,109.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,109.64,
THP CEPHALEXIN (Keflex) 500 MG CAP #4 [KHKS],6192733,CDM,253,RC,60687-0163-01QQ,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
THP CEPHALEXIN (Keflex) 500 MG CAP #4 [KHKS],6192733,CDM,253,RC,60687-0163-01QQ,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
THP ONDANSETRON (Zofran) ODT 4MG  #4[KHKS],6192734,CDM,253,RC,16714-0200-30QQ,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
THP ONDANSETRON (Zofran) ODT 4MG  #4[KHKS],6192734,CDM,253,RC,16714-0200-30QQ,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
THP CIPROFLOX/DEX (Ciprodex) 0.3%-0.1% OTIC 7.5 ML [KHKS],6192736,CDM,253,RC,00078-0799-75QQ,NDC,,,Outpatient,1,EA,168.72,,,,80,,134.97,percent of total billed charges,,,,85,143.41,percent of total billed charges,,,77.7,,131.09,percent of total billed charges,,,95,,160.28,percent of total billed charges,,,60,,101.23,percent of total billed charges,,101.23,160.28,
THP CIPROFLOX/DEX (Ciprodex) 0.3%-0.1% OTIC 7.5 ML [KHKS],6192736,CDM,253,RC,00078-0799-75QQ,NDC,,,Inpatient,1,EA,168.72,,,,80,,134.97,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,131.09,percent of total billed charges,,,95,,160.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,160.28,
THP OFLOXACIN (Ocuflox) 0.3% OPHTH SOL [KHKS],6192737,CDM,253,RC,17478-0713-10QQ,NDC,,,Outpatient,1,EA,14.21,,,,80,,11.37,percent of total billed charges,,,,85,12.08,percent of total billed charges,,,77.7,,11.04,percent of total billed charges,,,95,,13.5,percent of total billed charges,,,60,,8.53,percent of total billed charges,,8.53,13.5,
THP OFLOXACIN (Ocuflox) 0.3% OPHTH SOL [KHKS],6192737,CDM,253,RC,17478-0713-10QQ,NDC,,,Inpatient,1,EA,14.21,,,,80,,11.37,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.04,percent of total billed charges,,,95,,13.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.5,
THP CIPROFLOXACIN (Cipro) 500 MG TAB #4 [KHKS],6192738,CDM,253,RC,63739-0559-10QQ,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
THP CIPROFLOXACIN (Cipro) 500 MG TAB #4 [KHKS],6192738,CDM,253,RC,63739-0559-10QQ,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
THP NITROGLYCERIN (Nitrostat) SL-TAB 0.4MG #25 [KHKS],6192739,CDM,253,RC,00071-0418-13QQ,NDC,,,Outpatient,1,EA,224.27,,,,80,,179.41,percent of total billed charges,,,,85,190.63,percent of total billed charges,,,77.7,,174.25,percent of total billed charges,,,95,,213.05,percent of total billed charges,,,60,,134.56,percent of total billed charges,,134.56,213.05,
THP NITROGLYCERIN (Nitrostat) SL-TAB 0.4MG #25 [KHKS],6192739,CDM,253,RC,00071-0418-13QQ,NDC,,,Inpatient,1,EA,224.27,,,,80,,179.41,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,174.25,percent of total billed charges,,,95,,213.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,213.05,
THP CLINDAMYCIN (Cleocin) 150 MG CAP #4 [KHKS],6192740,CDM,253,RC,00904-5959-61QQ,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
THP CLINDAMYCIN (Cleocin) 150 MG CAP #4 [KHKS],6192740,CDM,253,RC,00904-5959-61QQ,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
THP NITROFURANTOIN (Macrobid) 100 MG CAP #4 [KHKS],6192741,CDM,253,RC,68084-0446-01QQ,NDC,,,Outpatient,1,EA,4.39,,,,80,,3.51,percent of total billed charges,,,,85,3.73,percent of total billed charges,,,77.7,,3.41,percent of total billed charges,,,95,,4.17,percent of total billed charges,,,60,,2.64,percent of total billed charges,,2.64,4.17,
THP NITROFURANTOIN (Macrobid) 100 MG CAP #4 [KHKS],6192741,CDM,253,RC,68084-0446-01QQ,NDC,,,Inpatient,1,EA,4.39,,,,80,,3.51,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.41,percent of total billed charges,,,95,,4.17,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.17,
THP CODEINE-GUAIFENESIN (Guaiatussin AC) 10 MG-100 MG/5 ML SYR 59 ML [KHKS],6192742,CDM,253,RC,50383-0087-04QQ,NDC,,,Outpatient,1,EA,9.73,,,,80,,7.78,percent of total billed charges,,,,85,8.27,percent of total billed charges,,,77.7,,7.56,percent of total billed charges,,,95,,9.24,percent of total billed charges,,,60,,5.84,percent of total billed charges,,5.84,9.24,
THP CODEINE-GUAIFENESIN (Guaiatussin AC) 10 MG-100 MG/5 ML SYR 59 ML [KHKS],6192742,CDM,253,RC,50383-0087-04QQ,NDC,,,Inpatient,1,EA,9.73,,,,80,,7.78,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.56,percent of total billed charges,,,95,,9.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.24,
THP NIFEDIPINE (Procardia) 10 mg CAP #4 [KHKS],6192743,CDM,253,RC,60687-0425-01QQ,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
THP NIFEDIPINE (Procardia) 10 mg CAP #4 [KHKS],6192743,CDM,253,RC,60687-0425-01QQ,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
THP CYCLOBENZAPRINE (Flexeril) 10 MG TAB #4 [KHKS],6192744,CDM,253,RC,69097-0846-07QQ,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
THP CYCLOBENZAPRINE (Flexeril) 10 MG TAB #4 [KHKS],6192744,CDM,253,RC,69097-0846-07QQ,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
THP DOXYCYCLINE (Vibra-Tab) 100 MG TAB #4 [KHKS],6192745,CDM,253,RC,00904-0430-04QQ,NDC,,,Outpatient,1,EA,10.75,,,,80,,8.6,percent of total billed charges,,,,85,9.14,percent of total billed charges,,,77.7,,8.35,percent of total billed charges,,,95,,10.21,percent of total billed charges,,,60,,6.45,percent of total billed charges,,6.45,10.21,
THP DOXYCYCLINE (Vibra-Tab) 100 MG TAB #4 [KHKS],6192745,CDM,253,RC,00904-0430-04QQ,NDC,,,Inpatient,1,EA,10.75,,,,80,,8.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.35,percent of total billed charges,,,95,,10.21,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.21,
THP NEOMYCIN/POLYMY B/HC (Cortisporin) OTIC  SUSP [KHKS],6192747,CDM,253,RC,24208-0635-62QQ,NDC,,,Outpatient,1,EA,143.73,,,,80,,114.98,percent of total billed charges,,,,85,122.17,percent of total billed charges,,,77.7,,111.68,percent of total billed charges,,,95,,136.54,percent of total billed charges,,,60,,86.24,percent of total billed charges,,86.24,136.54,
THP NEOMYCIN/POLYMY B/HC (Cortisporin) OTIC  SUSP [KHKS],6192747,CDM,253,RC,24208-0635-62QQ,NDC,,,Inpatient,1,EA,143.73,,,,80,,114.98,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,111.68,percent of total billed charges,,,95,,136.54,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,136.54,
THP ERYTHROMYCIN (Ilotycin) 0.5% OPHTH OINT 3.5 GM [KHKS],6192748,CDM,253,RC,17478-0070-35QQ,NDC,,,Outpatient,1,EA,27.13,,,,80,,21.7,percent of total billed charges,,,,85,23.06,percent of total billed charges,,,77.7,,21.08,percent of total billed charges,,,95,,25.77,percent of total billed charges,,,60,,16.28,percent of total billed charges,,16.28,25.77,
THP ERYTHROMYCIN (Ilotycin) 0.5% OPHTH OINT 3.5 GM [KHKS],6192748,CDM,253,RC,17478-0070-35QQ,NDC,,,Inpatient,1,EA,27.13,,,,80,,21.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,21.08,percent of total billed charges,,,95,,25.77,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,25.77,
THP ACETAMINOPHEN-HYDROCODONE (Norco) 325 MG-5 MG TAB #4 [KHKS],6192750,CDM,253,RC,00406-0123-62QQ,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
THP ACETAMINOPHEN-HYDROCODONE (Norco) 325 MG-5 MG TAB #4 [KHKS],6192750,CDM,253,RC,00406-0123-62QQ,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
THP METRONIDAZOLE (Flagyl) 250 MG TAB #4 [KHKS],6192751,CDM,253,RC,00904-1453-61QQ,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
THP METRONIDAZOLE (Flagyl) 250 MG TAB #4 [KHKS],6192751,CDM,253,RC,00904-1453-61QQ,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
THP IBUPROFEN (Motrin) 800 MG TAB #4 [KHKS],6192752,CDM,253,RC,60687-0468-01QQ,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
THP IBUPROFEN (Motrin) 800 MG TAB #4 [KHKS],6192752,CDM,253,RC,60687-0468-01QQ,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
THP LABETALOL (Normodyne) 100 MG TAB #4 [KHKS],6192753,CDM,253,RC,23155-0723-01QQ,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
THP LABETALOL (Normodyne) 100 MG TAB #4 [KHKS],6192753,CDM,253,RC,23155-0723-01QQ,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
THP LEVOFLOXACIN (Levaquin) 500 MG TAB #2 [KHKS],6192754,CDM,253,RC,00904-6352-61QQ,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
THP LEVOFLOXACIN (Levaquin) 500 MG TAB #2 [KHKS],6192754,CDM,253,RC,00904-6352-61QQ,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
THP LORAZEPAM (Ativan) 0.5 MG TAB #4 [KHKS],6192755,CDM,253,RC,69315-0904-01QQ,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
THP LORAZEPAM (Ativan) 0.5 MG TAB #4 [KHKS],6192755,CDM,253,RC,69315-0904-01QQ,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
THP MECLIZINE (Antivert) 25 MG TAB #4 [KHKS],6192756,CDM,253,RC,00904-6517-61QQ,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
THP MECLIZINE (Antivert) 25 MG TAB #4 [KHKS],6192756,CDM,253,RC,00904-6517-61QQ,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
THP METOCLOPRAMIDE (Reglan) 10 MG TAB #4 [KHKS],6192757,CDM,253,RC,68084-0676-01QQ,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
THP METOCLOPRAMIDE (Reglan) 10 MG TAB #4 [KHKS],6192757,CDM,253,RC,68084-0676-01QQ,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
Sodium Chloride 0.9% IV Sol 100 mL [KHKS],6206580,CDM,250,RC,00990-7984-37,NDC,,,Outpatient,100,ML,6.91,,,,80,,5.53,percent of total billed charges,,,,85,5.87,percent of total billed charges,,,77.7,,5.37,percent of total billed charges,,,95,,6.57,percent of total billed charges,,,60,,4.15,percent of total billed charges,,4.15,6.57,
Sodium Chloride 0.9% IV Sol 100 mL [KHKS],6206580,CDM,250,RC,00990-7984-37,NDC,,,Inpatient,100,ML,6.91,,,,80,,5.53,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.37,percent of total billed charges,,,95,,6.57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.57,
sodium chloride 0.9% Inj Sol 10 mL Vial [KHKS],6206645,CDM,250,RC,63323-0186-10,NDC,,,Outpatient,10,ML,3.2,,,,80,,2.56,percent of total billed charges,,,,85,2.72,percent of total billed charges,,,77.7,,2.49,percent of total billed charges,,,95,,3.04,percent of total billed charges,,,60,,1.92,percent of total billed charges,,1.92,3.04,
sodium chloride 0.9% Inj Sol 10 mL Vial [KHKS],6206645,CDM,250,RC,63323-0186-10,NDC,,,Inpatient,10,ML,3.2,,,,80,,2.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.49,percent of total billed charges,,,95,,3.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.04,
sodium chloride 0.9% FLUSH SYG 10 mL [KHKS],6208132,CDM,250,RC,63807-0100-01,NDC,,,Outpatient,10,ML,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
sodium chloride 0.9% FLUSH SYG 10 mL [KHKS],6208132,CDM,250,RC,63807-0100-01,NDC,,,Inpatient,10,ML,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
Lactated Ringers Injection Sol 1000 mL [KHKS],6208150,CDM,636,RC,J7120,HCPCS,00409-7953-09,NDC,Outpatient,1000,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,50,1.6,fee schedule,,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,60,,11.34,percent of total billed charges,,1.6,17.96,
Lactated Ringers Injection Sol 1000 mL [KHKS],6208150,CDM,636,RC,J7120,HCPCS,00409-7953-09,NDC,Inpatient,1000,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.96,
Nitroglycerin (Nitrobid) patch removal [KHKS],6212321,CDM,250,RC,99999-9999-91,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
Nitroglycerin (Nitrobid) patch removal [KHKS],6212321,CDM,250,RC,99999-9999-91,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
fentanyl patch removal [KHKS],6212326,CDM,250,RC,99999-9999-89,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
fentanyl patch removal [KHKS],6212326,CDM,250,RC,99999-9999-89,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
rivastigmine (Exelon) patch removal [KHKS],6212351,CDM,250,RC,99999-9999-97,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
rivastigmine (Exelon) patch removal [KHKS],6212351,CDM,250,RC,99999-9999-97,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
lidocaine patch removal [KHKS],6212366,CDM,250,RC,99999-9999-90,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
lidocaine patch removal [KHKS],6212366,CDM,250,RC,99999-9999-90,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
nicotine patch removal [KHKS],6212386,CDM,250,RC,99999-9999-92,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
nicotine patch removal [KHKS],6212386,CDM,250,RC,99999-9999-92,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
Al hydroxide/Mg hydroxide/simethicone 400 mg-400 mg-40 mg/5 mL Susp [KHKS],6212608,CDM,250,RC,62372-0500-12,NDC,,,Outpatient,5,ML,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
Al hydroxide/Mg hydroxide/simethicone 400 mg-400 mg-40 mg/5 mL Susp [KHKS],6212608,CDM,250,RC,62372-0500-12,NDC,,,Inpatient,5,ML,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
GI Cocktail 50mL [KHKS],6212610,CDM,250,RC,62372-0500-12QQ,NDC,,,Outpatient,50,ML,9.63,,,,80,,7.7,percent of total billed charges,,,,85,8.19,percent of total billed charges,,,77.7,,7.48,percent of total billed charges,,,95,,9.14,percent of total billed charges,,,60,,5.78,percent of total billed charges,,5.78,9.14,
GI Cocktail 50mL [KHKS],6212610,CDM,250,RC,62372-0500-12QQ,NDC,,,Inpatient,50,ML,9.63,,,,80,,7.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.48,percent of total billed charges,,,95,,9.14,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.14,
oxymetazoline Nasal (Afrin)-lidocaine 4% Sol 1:1 Spray 15mL [KHKS],6212717,CDM,250,RC,11523-1159-01QQ,NDC,,,Outpatient,15,EA,78.75,,,,80,,63,percent of total billed charges,,,,85,66.94,percent of total billed charges,,,77.7,,61.19,percent of total billed charges,,,95,,74.81,percent of total billed charges,,,60,,47.25,percent of total billed charges,,47.25,74.81,
oxymetazoline Nasal (Afrin)-lidocaine 4% Sol 1:1 Spray 15mL [KHKS],6212717,CDM,250,RC,11523-1159-01QQ,NDC,,,Inpatient,15,EA,78.75,,,,80,,63,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,61.19,percent of total billed charges,,,95,,74.81,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,74.81,
fluconazole 200 mg/100 mL-NS PREMIX IV Sol [KHKS],6214181,CDM,636,RC,J1450,HCPCS,00409-4688-18,NDC,Outpatient,100,ML,26.86,,,,80,,21.49,percent of total billed charges,,,,50,1.5,fee schedule,,,77.7,,20.87,percent of total billed charges,,,95,,25.52,percent of total billed charges,,,60,,16.12,percent of total billed charges,,1.5,25.52,
fluconazole 200 mg/100 mL-NS PREMIX IV Sol [KHKS],6214181,CDM,636,RC,J1450,HCPCS,00409-4688-18,NDC,Inpatient,100,ML,26.86,,,,80,,21.49,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,20.87,percent of total billed charges,,,95,,25.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,25.52,
oxytocin 10 units/mL Inj Sol 1 mL [KHKS],6214182,CDM,636,RC,J2590,HCPCS,42023-0116-25,NDC,Outpatient,1,ML,12.96,,,,80,,10.37,percent of total billed charges,,,,50,0.53,fee schedule,,,77.7,,10.07,percent of total billed charges,,,95,,12.31,percent of total billed charges,,,60,,7.78,percent of total billed charges,,0.53,12.31,
oxytocin 10 units/mL Inj Sol 1 mL [KHKS],6214182,CDM,636,RC,J2590,HCPCS,42023-0116-25,NDC,Inpatient,1,ML,12.96,,,,80,,10.37,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.07,percent of total billed charges,,,95,,12.31,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,12.31,
sodium chloride 0.9% INH Sol 3 mL [KHKS],6214297,CDM,250,RC,76204-0300-03,NDC,,,Outpatient,3,ML,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
sodium chloride 0.9% INH Sol 3 mL [KHKS],6214297,CDM,250,RC,76204-0300-03,NDC,,,Inpatient,3,ML,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
ibuprofen 100 mg/5 mL Oral Susp 5 mL [KHKS],6214298,CDM,250,RC,00121-0917-00,NDC,,,Outpatient,5,ML,2.82,,,,80,,2.26,percent of total billed charges,,,,85,2.4,percent of total billed charges,,,77.7,,2.19,percent of total billed charges,,,95,,2.68,percent of total billed charges,,,60,,1.69,percent of total billed charges,,1.69,2.68,
ibuprofen 100 mg/5 mL Oral Susp 5 mL [KHKS],6214298,CDM,250,RC,00121-0917-00,NDC,,,Inpatient,5,ML,2.82,,,,80,,2.26,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.19,percent of total billed charges,,,95,,2.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.68,
ibuprofen 100 mg/5 mL Oral Susp 5 mL [KHKS],6214299,CDM,250,RC,68094-0494-62,NDC,,,Outpatient,5,ML,2.61,,,,80,,2.09,percent of total billed charges,,,,85,2.22,percent of total billed charges,,,77.7,,2.03,percent of total billed charges,,,95,,2.48,percent of total billed charges,,,60,,1.57,percent of total billed charges,,1.57,2.48,
ibuprofen 100 mg/5 mL Oral Susp 5 mL [KHKS],6214299,CDM,250,RC,68094-0494-62,NDC,,,Inpatient,5,ML,2.61,,,,80,,2.09,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.03,percent of total billed charges,,,95,,2.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.48,
Sodium Chloride 0.9% IV Sol 100 mL [KHKS],6214302,CDM,250,RC,00264-1800-32,NDC,,,Outpatient,100,ML,8.74,,,,80,,6.99,percent of total billed charges,,,,85,7.43,percent of total billed charges,,,77.7,,6.79,percent of total billed charges,,,95,,8.3,percent of total billed charges,,,60,,5.25,percent of total billed charges,,5.25,8.3,
Sodium Chloride 0.9% IV Sol 100 mL [KHKS],6214302,CDM,250,RC,00264-1800-32,NDC,,,Inpatient,100,ML,8.74,,,,80,,6.99,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.79,percent of total billed charges,,,95,,8.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,8.3,
ropivacaine 0.2% (2 mg/mL) Inj Sol 200 mL [KHKS],6214303,CDM,636,RC,J2795,HCPCS,25021-0671-67,NDC,Outpatient,200,ML,98.2,,,,80,,78.56,percent of total billed charges,,,,50,0.06,fee schedule,,,77.7,,76.3,percent of total billed charges,,,95,,93.29,percent of total billed charges,,,60,,58.92,percent of total billed charges,,0.06,93.29,
ropivacaine 0.2% (2 mg/mL) Inj Sol 200 mL [KHKS],6214303,CDM,636,RC,J2795,HCPCS,25021-0671-67,NDC,Inpatient,200,ML,98.2,,,,80,,78.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,76.3,percent of total billed charges,,,95,,93.29,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,93.29,
pioglitazone 15 mg Oral Tab [KHKS],6214307,CDM,250,RC,60687-0391-01,NDC,,,Outpatient,1,EA,3.78,,,,80,,3.02,percent of total billed charges,,,,85,3.21,percent of total billed charges,,,77.7,,2.94,percent of total billed charges,,,95,,3.59,percent of total billed charges,,,60,,2.27,percent of total billed charges,,2.27,3.59,
pioglitazone 15 mg Oral Tab [KHKS],6214307,CDM,250,RC,60687-0391-01,NDC,,,Inpatient,1,EA,3.78,,,,80,,3.02,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.94,percent of total billed charges,,,95,,3.59,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.59,
phytonadione 5 mg Tab [KHKS],6214308,CDM,250,RC,16714-0973-01,NDC,,,Outpatient,1,EA,200.96,,,,80,,160.77,percent of total billed charges,,,,85,170.82,percent of total billed charges,,,77.7,,156.15,percent of total billed charges,,,95,,190.91,percent of total billed charges,,,60,,120.58,percent of total billed charges,,120.58,190.91,
phytonadione 5 mg Tab [KHKS],6214308,CDM,250,RC,16714-0973-01,NDC,,,Inpatient,1,EA,200.96,,,,80,,160.77,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,156.15,percent of total billed charges,,,95,,190.91,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,190.91,
pentoxifylline 400 mg Oral Tab-ER [KHKS],6214309,CDM,250,RC,00904-5448-61,NDC,,,Outpatient,1,EA,4.49,,,,80,,3.6,percent of total billed charges,,,,85,3.82,percent of total billed charges,,,77.7,,3.49,percent of total billed charges,,,95,,4.27,percent of total billed charges,,,60,,2.7,percent of total billed charges,,2.7,4.27,
pentoxifylline 400 mg Oral Tab-ER [KHKS],6214309,CDM,250,RC,00904-5448-61,NDC,,,Inpatient,1,EA,4.49,,,,80,,3.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.49,percent of total billed charges,,,95,,4.27,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.27,
promethazine 25 mg Oral Tab [KHKS],6214310,CDM,250,RC,00904-6461-61,NDC,,,Outpatient,1,EA,2.86,,,,80,,2.28,percent of total billed charges,,,,85,2.43,percent of total billed charges,,,77.7,,2.22,percent of total billed charges,,,95,,2.71,percent of total billed charges,,,60,,1.71,percent of total billed charges,,1.71,2.71,
promethazine 25 mg Oral Tab [KHKS],6214310,CDM,250,RC,00904-6461-61,NDC,,,Inpatient,1,EA,2.86,,,,80,,2.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.22,percent of total billed charges,,,95,,2.71,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.71,
sodium chloride Nasal 0.65% Spray 44 mL [KHKS],6214311,CDM,250,RC,00904-3865-75,NDC,,,Outpatient,44,EA,6.3,,,,80,,5.04,percent of total billed charges,,,,85,5.36,percent of total billed charges,,,77.7,,4.9,percent of total billed charges,,,95,,5.99,percent of total billed charges,,,60,,3.78,percent of total billed charges,,3.78,5.99,
sodium chloride Nasal 0.65% Spray 44 mL [KHKS],6214311,CDM,250,RC,00904-3865-75,NDC,,,Inpatient,44,EA,6.3,,,,80,,5.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.9,percent of total billed charges,,,95,,5.99,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.99,
fentaNYL 100 mcg/hr Patch [KHKS],6216246,CDM,250,RC,00378-9124-98,NDC,,,Outpatient,1,EA,160.08,,,,80,,128.06,percent of total billed charges,,,,85,136.07,percent of total billed charges,,,77.7,,124.38,percent of total billed charges,,,95,,152.08,percent of total billed charges,,,60,,96.05,percent of total billed charges,,96.05,152.08,
fentaNYL 100 mcg/hr Patch [KHKS],6216246,CDM,250,RC,00378-9124-98,NDC,,,Inpatient,1,EA,160.08,,,,80,,128.06,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,124.38,percent of total billed charges,,,95,,152.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,152.08,
simvastatin 10 mg Tab [KHKS],6216248,CDM,250,RC,63739-0571-10,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
simvastatin 10 mg Tab [KHKS],6216248,CDM,250,RC,63739-0571-10,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
nicotine 14 mg/24 hr Patch [KHKS],6216250,CDM,250,RC,43598-0447-74,NDC,,,Outpatient,1,EA,6.4,,,,80,,5.12,percent of total billed charges,,,,85,5.44,percent of total billed charges,,,77.7,,4.97,percent of total billed charges,,,95,,6.08,percent of total billed charges,,,60,,3.84,percent of total billed charges,,3.84,6.08,
nicotine 14 mg/24 hr Patch [KHKS],6216250,CDM,250,RC,43598-0447-74,NDC,,,Inpatient,1,EA,6.4,,,,80,,5.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.97,percent of total billed charges,,,95,,6.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.08,
simethicone 80 mg Chew Tab [KHKS],6216252,CDM,250,RC,69618-0033-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
simethicone 80 mg Chew Tab [KHKS],6216252,CDM,250,RC,69618-0033-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
cholecalciferol 25 mcg (1000 intl units) Tab UD [KHKS],6216285,CDM,250,RC,80681-0169-00,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
cholecalciferol 25 mcg (1000 intl units) Tab UD [KHKS],6216285,CDM,250,RC,80681-0169-00,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
zinc sulfate 220 mg Cap [KHKS],6216297,CDM,250,RC,80681-0135-00,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
zinc sulfate 220 mg Cap [KHKS],6216297,CDM,250,RC,80681-0135-00,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
lidocaine 1% PF Inj Sol 5 mL [KHKS],6216302,CDM,250,RC,63323-0492-57,NDC,,,Outpatient,5,ML,13.36,,,,80,,10.68,percent of total billed charges,,,,85,11.36,percent of total billed charges,,,77.7,,10.38,percent of total billed charges,,,95,,12.69,percent of total billed charges,,,60,,8.01,percent of total billed charges,,8.01,12.69,
lidocaine 1% PF Inj Sol 5 mL [KHKS],6216302,CDM,250,RC,63323-0492-57,NDC,,,Inpatient,5,ML,13.36,,,,80,,10.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.38,percent of total billed charges,,,95,,12.69,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,12.69,
lidocaine 2% (20 mg/mL) PF Inj Sol 2 mL [KHKS],6216306,CDM,636,RC,J2003,HCPCS,55150-0164-02,NDC,Outpatient,2,ML,13.5,,,,80,,10.8,percent of total billed charges,,,,85,11.48,percent of total billed charges,,,77.7,,10.49,percent of total billed charges,,,95,,12.83,percent of total billed charges,,,60,,8.1,percent of total billed charges,,8.1,12.83,
lidocaine 2% (20 mg/mL) PF Inj Sol 2 mL [KHKS],6216306,CDM,636,RC,J2003,HCPCS,55150-0164-02,NDC,Inpatient,2,ML,13.5,,,,80,,10.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.49,percent of total billed charges,,,95,,12.83,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,12.83,
lidocaine 2% 20 mg/mL PF IV Sol 5 mL Vial [KHKS],6216309,CDM,636,RC,J2003,HCPCS,76329-3390-01,NDC,Outpatient,5,ML,24.3,,,,80,,19.44,percent of total billed charges,,,,85,20.66,percent of total billed charges,,,77.7,,18.88,percent of total billed charges,,,95,,23.09,percent of total billed charges,,,60,,14.58,percent of total billed charges,,14.58,23.09,
lidocaine 2% 20 mg/mL PF IV Sol 5 mL Vial [KHKS],6216309,CDM,636,RC,J2003,HCPCS,76329-3390-01,NDC,Inpatient,5,ML,24.3,,,,80,,19.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,18.88,percent of total billed charges,,,95,,23.09,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,23.09,
lidocaine 2% 20 mg/mL Inj Sol 10 mL [KHKS],6216336,CDM,636,RC,J2003,HCPCS,63323-0486-17,NDC,Outpatient,10,ML,10.8,,,,80,,8.64,percent of total billed charges,,,,85,9.18,percent of total billed charges,,,77.7,,8.39,percent of total billed charges,,,95,,10.26,percent of total billed charges,,,60,,6.48,percent of total billed charges,,6.48,10.26,
lidocaine 2% 20 mg/mL Inj Sol 10 mL [KHKS],6216336,CDM,636,RC,J2003,HCPCS,63323-0486-17,NDC,Inpatient,10,ML,10.8,,,,80,,8.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.39,percent of total billed charges,,,95,,10.26,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.26,
neostigmine 1 mg/mL Sol 10 mL [KHKS],6216341,CDM,636,RC,J2710,HCPCS,76014-0903-10,NDC,Outpatient,10,ML,60.09,,,,80,,48.07,percent of total billed charges,,,,50,0.76,fee schedule,,,77.7,,46.69,percent of total billed charges,,,95,,57.08,percent of total billed charges,,,60,,36.05,percent of total billed charges,,0.76,57.08,
neostigmine 1 mg/mL Sol 10 mL [KHKS],6216341,CDM,636,RC,J2710,HCPCS,76014-0903-10,NDC,Inpatient,10,ML,60.09,,,,80,,48.07,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,46.69,percent of total billed charges,,,95,,57.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,57.08,
misoprostol 100 mcg Tab [KHKS],6216343,CDM,250,RC,68084-0040-01,NDC,,,Outpatient,1,EA,7.44,,,,80,,5.95,percent of total billed charges,,,,85,6.32,percent of total billed charges,,,77.7,,5.78,percent of total billed charges,,,95,,7.07,percent of total billed charges,,,60,,4.46,percent of total billed charges,,4.46,7.07,
misoprostol 100 mcg Tab [KHKS],6216343,CDM,250,RC,68084-0040-01,NDC,,,Inpatient,1,EA,7.44,,,,80,,5.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.78,percent of total billed charges,,,95,,7.07,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.07,
caspofungin 50 mg IV Inj [KHKS],6224071,CDM,636,RC,J0637,HCPCS,00006-3822-10,NDC,Outpatient,1,EA,749.71,,,,80,,599.77,percent of total billed charges,,,,50,3.61,fee schedule,,,77.7,,582.53,percent of total billed charges,,,95,,712.23,percent of total billed charges,,,60,,449.83,percent of total billed charges,,3.61,712.23,
caspofungin 50 mg IV Inj [KHKS],6224071,CDM,636,RC,J0637,HCPCS,00006-3822-10,NDC,Inpatient,1,EA,749.71,,,,80,,599.77,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,582.53,percent of total billed charges,,,95,,712.23,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,712.23,
clindamycin 150 mg/mL IV Sol 6 mL [KHKS],6224072,CDM,636,RC,J7036,HCPCS,72611-0642-25,NDC,Outpatient,6,ML,16.49,,,,80,,13.19,percent of total billed charges,,,,85,14.02,percent of total billed charges,,,77.7,,12.81,percent of total billed charges,,,95,,15.66,percent of total billed charges,,,60,,9.89,percent of total billed charges,,9.89,15.66,
clindamycin 150 mg/mL IV Sol 6 mL [KHKS],6224072,CDM,636,RC,J7036,HCPCS,72611-0642-25,NDC,Inpatient,6,ML,16.49,,,,80,,13.19,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.81,percent of total billed charges,,,95,,15.66,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.66,
clindamycin 150 mg/mL IV Sol 6 mL [KHKS],6224073,CDM,636,RC,J7036,HCPCS,00009-0902-18,NDC,Outpatient,6,ML,15.35,,,,80,,12.28,percent of total billed charges,,,,85,13.05,percent of total billed charges,,,77.7,,11.93,percent of total billed charges,,,95,,14.58,percent of total billed charges,,,60,,9.21,percent of total billed charges,,9.21,14.58,
clindamycin 150 mg/mL IV Sol 6 mL [KHKS],6224073,CDM,636,RC,J7036,HCPCS,00009-0902-18,NDC,Inpatient,6,ML,15.35,,,,80,,12.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.93,percent of total billed charges,,,95,,14.58,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,14.58,
inFLIXimab 100 mg IV Inj [KHKS],6224110,CDM,636,RC,J1745,HCPCS,57894-0030-01,NDC,Outpatient,1,EA,2592.55,,,,80,,2074.04,percent of total billed charges,,,,50,20.95,fee schedule,,,77.7,,2014.41,percent of total billed charges,,,95,,2462.93,percent of total billed charges,,,60,,1555.53,percent of total billed charges,,20.95,2462.93,
inFLIXimab 100 mg IV Inj [KHKS],6224110,CDM,636,RC,J1745,HCPCS,57894-0030-01,NDC,Inpatient,1,EA,2592.55,,,,80,,2074.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2014.41,percent of total billed charges,,,95,,2462.93,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2462.93,
ocrelizumab 300 mg/10 mL IV Sol 10 mL [KHKS],6224145,CDM,636,RC,J2350,HCPCS,50242-0150-01,NDC,Outpatient,10,ML,39508.85,,,,80,,31607.08,percent of total billed charges,,,,50,36.28,fee schedule,,,77.7,,30698.38,percent of total billed charges,,,95,,37533.41,percent of total billed charges,,,60,,23705.31,percent of total billed charges,,36.28,37533.41,
ocrelizumab 300 mg/10 mL IV Sol 10 mL [KHKS],6224145,CDM,636,RC,J2350,HCPCS,50242-0150-01,NDC,Inpatient,10,ML,39508.85,,,,80,,31607.08,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,30698.38,percent of total billed charges,,,95,,37533.41,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,37533.41,
Banana Bag 1000 mL [KHKS],6226457,CDM,250,RC,54643-5649-01QQ,NDC,,,Outpatient,1,ML,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
Banana Bag 1000 mL [KHKS],6226457,CDM,250,RC,54643-5649-01QQ,NDC,,,Inpatient,1,ML,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
Dextrose 5% with 0.45% NaCl and KCl 10 mEq/L IV PREMIX Sol 1000 mL [KHKS],6226460,CDM,636,RC,J3480,HCPCS,00990-7993-09,NDC,Outpatient,1000,ML,25.44,,,,80,,20.35,percent of total billed charges,,,,50,0.09,fee schedule,,,77.7,,19.77,percent of total billed charges,,,95,,24.17,percent of total billed charges,,,60,,15.26,percent of total billed charges,,0.09,24.17,
Dextrose 5% with 0.45% NaCl and KCl 10 mEq/L IV PREMIX Sol 1000 mL [KHKS],6226460,CDM,636,RC,J3480,HCPCS,00990-7993-09,NDC,Inpatient,1000,ML,25.44,,,,80,,20.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.77,percent of total billed charges,,,95,,24.17,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,24.17,
riTUXimab 10 mg/mL Sol 10 mL [KHKS],6226474,CDM,636,RC,J9312,HCPCS,50242-0051-21,NDC,Outpatient,10,ML,2085.73,,,,80,,1668.59,percent of total billed charges,,,,50,50.79,fee schedule,,,77.7,,1620.62,percent of total billed charges,,,95,,1981.45,percent of total billed charges,,,60,,1251.44,percent of total billed charges,,50.79,1981.45,
riTUXimab 10 mg/mL Sol 10 mL [KHKS],6226474,CDM,636,RC,J9312,HCPCS,50242-0051-21,NDC,Inpatient,10,ML,2085.73,,,,80,,1668.59,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1620.62,percent of total billed charges,,,95,,1981.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1981.45,
tobramycin 40 mg/mL Inj Sol 2 mL Vial [KHKS],6226479,CDM,636,RC,J3260,HCPCS,00703-9402-04,NDC,Outpatient,2,ML,7.13,,,,80,,5.7,percent of total billed charges,,,,50,2.05,fee schedule,,,77.7,,5.54,percent of total billed charges,,,95,,6.77,percent of total billed charges,,,60,,4.28,percent of total billed charges,,2.05,6.77,
tobramycin 40 mg/mL Inj Sol 2 mL Vial [KHKS],6226479,CDM,636,RC,J3260,HCPCS,00703-9402-04,NDC,Inpatient,2,ML,7.13,,,,80,,5.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.54,percent of total billed charges,,,95,,6.77,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.77,
Dextrose 10% in Water IV Sol 1000 mL [KHKS],6227829,CDM,250,RC,00990-7930-09,NDC,,,Outpatient,1000,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,85,16.07,percent of total billed charges,,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,60,,11.34,percent of total billed charges,,11.34,17.96,
Dextrose 10% in Water IV Sol 1000 mL [KHKS],6227829,CDM,250,RC,00990-7930-09,NDC,,,Inpatient,1000,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.96,
glycine IRRIG 1.5% Sol 3000 mL [KHKS],6227833,CDM,250,RC,00990-7974-08,NDC,,,Outpatient,3000,ML,48.42,,,,80,,38.74,percent of total billed charges,,,,85,41.16,percent of total billed charges,,,77.7,,37.62,percent of total billed charges,,,95,,46,percent of total billed charges,,,60,,29.05,percent of total billed charges,,29.05,46,
glycine IRRIG 1.5% Sol 3000 mL [KHKS],6227833,CDM,250,RC,00990-7974-08,NDC,,,Inpatient,3000,ML,48.42,,,,80,,38.74,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,37.62,percent of total billed charges,,,95,,46,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,46,
iodixanol 320 mg/mL Inj Sol 100 mL [KHKS],6227851,CDM,636,RC,Q9967,HCPCS,00407-2223-17,NDC,Outpatient,100,ML,500,,,,80,,400,percent of total billed charges,,,,50,2.53,fee schedule,,,77.7,,388.5,percent of total billed charges,,,95,,475,percent of total billed charges,,,60,,300,percent of total billed charges,,2.53,475,
iodixanol 320 mg/mL Inj Sol 100 mL [KHKS],6227851,CDM,636,RC,Q9967,HCPCS,00407-2223-17,NDC,Inpatient,100,ML,500,,,,80,,400,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,388.5,percent of total billed charges,,,95,,475,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,475,
iodixanol 320 mg/mL Inj Sol 50 mL [KHKS],6227853,CDM,636,RC,Q9967,HCPCS,00407-2223-62,NDC,Outpatient,50,ML,250,,,,80,,200,percent of total billed charges,,,,50,2.53,fee schedule,,,77.7,,194.25,percent of total billed charges,,,95,,237.5,percent of total billed charges,,,60,,150,percent of total billed charges,,2.53,237.5,
iodixanol 320 mg/mL Inj Sol 50 mL [KHKS],6227853,CDM,636,RC,Q9967,HCPCS,00407-2223-62,NDC,Inpatient,50,ML,250,,,,80,,200,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,194.25,percent of total billed charges,,,95,,237.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,237.5,
ketamine 10 mg/mL Inj Sol 20 mL [KHKS],6227860,CDM,250,RC,42023-0113-10,NDC,,,Outpatient,20,ML,71.21,,,,80,,56.97,percent of total billed charges,,,,85,60.53,percent of total billed charges,,,77.7,,55.33,percent of total billed charges,,,95,,67.65,percent of total billed charges,,,60,,42.73,percent of total billed charges,,42.73,67.65,
ketamine 10 mg/mL Inj Sol 20 mL [KHKS],6227860,CDM,250,RC,42023-0113-10,NDC,,,Inpatient,20,ML,71.21,,,,80,,56.97,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,55.33,percent of total billed charges,,,95,,67.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,67.65,
traMADol 50 mg Tab [KHKS],6227863,CDM,250,RC,00904-7179-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
traMADol 50 mg Tab [KHKS],6227863,CDM,250,RC,00904-7179-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
oxyCODONE 10 mg Tab [KHKS],6227864,CDM,250,RC,59011-0410-20,NDC,,,Outpatient,1,EA,17.22,,,,80,,13.78,percent of total billed charges,,,,85,14.64,percent of total billed charges,,,77.7,,13.38,percent of total billed charges,,,95,,16.36,percent of total billed charges,,,60,,10.33,percent of total billed charges,,10.33,16.36,
oxyCODONE 10 mg Tab [KHKS],6227864,CDM,250,RC,59011-0410-20,NDC,,,Inpatient,1,EA,17.22,,,,80,,13.78,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,13.38,percent of total billed charges,,,95,,16.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,16.36,
morphine 15 mg Tab [KHKS],6227865,CDM,250,RC,00832-0273-11,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
morphine 15 mg Tab [KHKS],6227865,CDM,250,RC,00832-0273-11,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
loratadine 10 mg Tab [KHKS],6228163,CDM,250,RC,58602-0702-04,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
loratadine 10 mg Tab [KHKS],6228163,CDM,250,RC,58602-0702-04,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
lanolin topical Cream 7 gm [KHKS],6228230,CDM,250,RC,44677-0103-02,NDC,,,Outpatient,7,EA,7.2,,,,80,,5.76,percent of total billed charges,,,,85,6.12,percent of total billed charges,,,77.7,,5.6,percent of total billed charges,,,95,,6.84,percent of total billed charges,,,60,,4.32,percent of total billed charges,,4.32,6.84,
lanolin topical Cream 7 gm [KHKS],6228230,CDM,250,RC,44677-0103-02,NDC,,,Inpatient,7,EA,7.2,,,,80,,5.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.6,percent of total billed charges,,,95,,6.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.84,
labetalol 5 mg/mL IV Sol 40 mL [KHKS],6228231,CDM,636,RC,J1920,HCPCS,72266-0103-01,NDC,Outpatient,1,ML,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
labetalol 5 mg/mL IV Sol 40 mL [KHKS],6228231,CDM,636,RC,J1920,HCPCS,72266-0103-01,NDC,Inpatient,1,ML,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
hydrALAZINE 25 mg Tab [KHKS],6228261,CDM,250,RC,63739-0327-10,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
hydrALAZINE 25 mg Tab [KHKS],6228261,CDM,250,RC,63739-0327-10,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
aprepitant 40 mg Cap [KHKS],6228349,CDM,250,RC,00781-2321-51,NDC,,,Outpatient,1,EA,247.36,,,,80,,197.88,percent of total billed charges,,,,85,210.26,percent of total billed charges,,,77.7,,192.2,percent of total billed charges,,,95,,234.99,percent of total billed charges,,,60,,148.41,percent of total billed charges,,148.41,234.99,
aprepitant 40 mg Cap [KHKS],6228349,CDM,250,RC,00781-2321-51,NDC,,,Inpatient,1,EA,247.36,,,,80,,197.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,192.2,percent of total billed charges,,,95,,234.99,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,234.99,
erythromycin ophthalmic 0.5% Oint 3.5 gm [KHKS],6228366,CDM,250,RC,17478-0070-35,NDC,,,Outpatient,3.5,EA,55.95,,,,80,,44.76,percent of total billed charges,,,,85,47.56,percent of total billed charges,,,77.7,,43.47,percent of total billed charges,,,95,,53.15,percent of total billed charges,,,60,,33.57,percent of total billed charges,,33.57,53.15,
erythromycin ophthalmic 0.5% Oint 3.5 gm [KHKS],6228366,CDM,250,RC,17478-0070-35,NDC,,,Inpatient,3.5,EA,55.95,,,,80,,44.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,43.47,percent of total billed charges,,,95,,53.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,53.15,
dexamethasone 10 mg/mL PF Prefilled-Syr Inj Sol [KHKS],6228416,CDM,636,RC,J1100,HCPCS,76045-0109-10,NDC,Outpatient,1,ML,20.81,,,,80,,16.65,percent of total billed charges,,,,50,0.08,fee schedule,,,77.7,,16.17,percent of total billed charges,,,95,,19.77,percent of total billed charges,,,60,,12.48,percent of total billed charges,,0.08,19.77,
dexamethasone 10 mg/mL PF Prefilled-Syr Inj Sol [KHKS],6228416,CDM,636,RC,J1100,HCPCS,76045-0109-10,NDC,Inpatient,1,ML,20.81,,,,80,,16.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,16.17,percent of total billed charges,,,95,,19.77,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,19.77,
candida albicans extract Sol 1 mL [KHKS],6228422,CDM,636,RC,59584-0138-01,NDC,,,Outpatient,1,ML,603.84,,,,80,,483.07,percent of total billed charges,,,,85,513.26,percent of total billed charges,,,77.7,,469.18,percent of total billed charges,,,95,,573.65,percent of total billed charges,,,60,,362.3,percent of total billed charges,,362.3,573.65,
candida albicans extract Sol 1 mL [KHKS],6228422,CDM,636,RC,59584-0138-01,NDC,,,Inpatient,1,ML,603.84,,,,80,,483.07,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,469.18,percent of total billed charges,,,95,,573.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,573.65,
bumetanide 1 mg Tab [KHKS],6228450,CDM,250,RC,42799-0120-02,NDC,,,Outpatient,1,EA,7.21,,,,80,,5.77,percent of total billed charges,,,,85,6.13,percent of total billed charges,,,77.7,,5.6,percent of total billed charges,,,95,,6.85,percent of total billed charges,,,60,,4.33,percent of total billed charges,,4.33,6.85,
bumetanide 1 mg Tab [KHKS],6228450,CDM,250,RC,42799-0120-02,NDC,,,Inpatient,1,EA,7.21,,,,80,,5.77,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.6,percent of total billed charges,,,95,,6.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.85,
budesonide-formoterol 160 mcg-4.5 mcg/inh 6 gm [KHKS],6228463,CDM,250,RC,00186-0370-28,NDC,,,Outpatient,6,EA,571.89,,,,80,,457.52,percent of total billed charges,,,,85,486.11,percent of total billed charges,,,77.7,,444.36,percent of total billed charges,,,95,,543.3,percent of total billed charges,,,60,,343.14,percent of total billed charges,,343.14,543.3,
budesonide-formoterol 160 mcg-4.5 mcg/inh 6 gm [KHKS],6228463,CDM,250,RC,00186-0370-28,NDC,,,Inpatient,6,EA,571.89,,,,80,,457.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,444.36,percent of total billed charges,,,95,,543.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,543.3,
diphenhydramine-zinc acetate Top 1%-0.1% Cream 28 gm [KHKS],6228481,CDM,250,RC,69968-0625-01,NDC,,,Outpatient,28,EA,9.54,,,,80,,7.63,percent of total billed charges,,,,85,8.11,percent of total billed charges,,,77.7,,7.41,percent of total billed charges,,,95,,9.07,percent of total billed charges,,,60,,5.73,percent of total billed charges,,5.73,9.07,
diphenhydramine-zinc acetate Top 1%-0.1% Cream 28 gm [KHKS],6228481,CDM,250,RC,69968-0625-01,NDC,,,Inpatient,28,EA,9.54,,,,80,,7.63,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.41,percent of total billed charges,,,95,,9.07,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.07,
bisacodyl 5 mg Oral EC Tab [KHKS],6228483,CDM,250,RC,00904-6407-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
bisacodyl 5 mg Oral EC Tab [KHKS],6228483,CDM,250,RC,00904-6407-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
bag balm Oint 240 gm [KHKS],6228484,CDM,250,RC,98193-0001-05,NDC,,,Outpatient,240,EA,16.27,,,,80,,13.02,percent of total billed charges,,,,85,13.83,percent of total billed charges,,,77.7,,12.64,percent of total billed charges,,,95,,15.46,percent of total billed charges,,,60,,9.76,percent of total billed charges,,9.76,15.46,
bag balm Oint 240 gm [KHKS],6228484,CDM,250,RC,98193-0001-05,NDC,,,Inpatient,240,EA,16.27,,,,80,,13.02,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.64,percent of total billed charges,,,95,,15.46,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.46,
atropine 1 mg/mL Inj Sol 1 mL [KHKS],6228573,CDM,636,RC,J0461,HCPCS,00517-1001-25,NDC,Outpatient,1,ML,61.06,,,,80,,48.84,percent of total billed charges,,,,50,0.07,fee schedule,,,77.7,,47.44,percent of total billed charges,,,95,,58,percent of total billed charges,,,60,,36.63,percent of total billed charges,,0.07,58,
atropine 1 mg/mL Inj Sol 1 mL [KHKS],6228573,CDM,636,RC,J0461,HCPCS,00517-1001-25,NDC,Inpatient,1,ML,61.06,,,,80,,48.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,47.44,percent of total billed charges,,,95,,58,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,58,
ampicillin-sulbactam 1.5 gm Inj Powd [KHKS],6228582,CDM,636,RC,J0295,HCPCS,67457-0348-10,NDC,Outpatient,1,EA,24.42,,,,80,,19.54,percent of total billed charges,,,,50,1.44,fee schedule,,,77.7,,18.97,percent of total billed charges,,,95,,23.2,percent of total billed charges,,,60,,14.65,percent of total billed charges,,1.44,23.2,
ampicillin-sulbactam 1.5 gm Inj Powd [KHKS],6228582,CDM,636,RC,J0295,HCPCS,67457-0348-10,NDC,Inpatient,1,EA,24.42,,,,80,,19.54,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,18.97,percent of total billed charges,,,95,,23.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,23.2,
adenosine 3 mg/mL IV Sol 2 mL [KHKS],6228584,CDM,636,RC,J0153,HCPCS,67457-0855-02,NDC,Outpatient,2,ML,22.5,,,,80,,18,percent of total billed charges,,,,50,0.33,fee schedule,,,77.7,,17.48,percent of total billed charges,,,95,,21.38,percent of total billed charges,,,60,,13.5,percent of total billed charges,,0.33,21.38,
adenosine 3 mg/mL IV Sol 2 mL [KHKS],6228584,CDM,636,RC,J0153,HCPCS,67457-0855-02,NDC,Inpatient,2,ML,22.5,,,,80,,18,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,17.48,percent of total billed charges,,,95,,21.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,21.38,
fluticasone-salmeterol 250 mcg-50 mcg INH [KHKS],6228585,CDM,250,RC,00173-0696-04,NDC,,,Outpatient,14,EA,409.68,,,,80,,327.74,percent of total billed charges,,,,85,348.23,percent of total billed charges,,,77.7,,318.32,percent of total billed charges,,,95,,389.2,percent of total billed charges,,,60,,245.81,percent of total billed charges,,245.81,389.2,
fluticasone-salmeterol 250 mcg-50 mcg INH [KHKS],6228585,CDM,250,RC,00173-0696-04,NDC,,,Inpatient,14,EA,409.68,,,,80,,327.74,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,318.32,percent of total billed charges,,,95,,389.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,389.2,
Dextrose 10% with 0.2% NaCl IV Sol 250 mL [KHKS],6228591,CDM,250,RC,00264-7623-20,NDC,,,Outpatient,250,ML,36.83,,,,80,,29.46,percent of total billed charges,,,,85,31.31,percent of total billed charges,,,77.7,,28.61,percent of total billed charges,,,95,,34.98,percent of total billed charges,,,60,,22.1,percent of total billed charges,,22.1,34.98,
Dextrose 10% with 0.2% NaCl IV Sol 250 mL [KHKS],6228591,CDM,250,RC,00264-7623-20,NDC,,,Inpatient,250,ML,36.83,,,,80,,29.46,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,28.61,percent of total billed charges,,,95,,34.98,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,34.98,
buprenorphine 8 mg SL Tab [KHKS],6228613,CDM,250,RC,00054-0177-13,NDC,,,Outpatient,1,EA,23.22,,,,80,,18.58,percent of total billed charges,,,,85,19.74,percent of total billed charges,,,77.7,,18.04,percent of total billed charges,,,95,,22.06,percent of total billed charges,,,60,,13.93,percent of total billed charges,,13.93,22.06,
buprenorphine 8 mg SL Tab [KHKS],6228613,CDM,250,RC,00054-0177-13,NDC,,,Inpatient,1,EA,23.22,,,,80,,18.58,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,18.04,percent of total billed charges,,,95,,22.06,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,22.06,
magnesium sulfate 50% Inj Sol 10gm/20 mL [KHKS],6228642,CDM,636,RC,J3475,HCPCS,63323-0642-20,NDC,Outpatient,20,ML,28.33,,,,80,,22.67,percent of total billed charges,,,,50,0.51,fee schedule,,,77.7,,22.01,percent of total billed charges,,,95,,26.92,percent of total billed charges,,,60,,17,percent of total billed charges,,0.51,26.92,
magnesium sulfate 50% Inj Sol 10gm/20 mL [KHKS],6228642,CDM,636,RC,J3475,HCPCS,63323-0642-20,NDC,Inpatient,20,ML,28.33,,,,80,,22.67,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,22.01,percent of total billed charges,,,95,,26.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,26.92,
magnesium oxide 400 mg Tab [KHKS],6228671,CDM,10006-0700-28,NDC,,,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
magnesium oxide 400 mg Tab [KHKS],6228671,CDM,10006-0700-28,NDC,,,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
methylPREDNISolone acetate 80 mg/mL Inj Susp [KHKS],6228672,CDM,636,RC,J1010,HCPCS,00703-0051-01,NDC,Outpatient,1,ML,51.48,,,,80,,41.18,percent of total billed charges,,,,85,43.76,percent of total billed charges,,,77.7,,40,percent of total billed charges,,,95,,48.91,percent of total billed charges,,,60,,30.89,percent of total billed charges,,30.89,48.91,
methylPREDNISolone acetate 80 mg/mL Inj Susp [KHKS],6228672,CDM,636,RC,J1010,HCPCS,00703-0051-01,NDC,Inpatient,1,ML,51.48,,,,80,,41.18,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,40,percent of total billed charges,,,95,,48.91,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,48.91,
menthol topical 4% Gel 89 mL [KHKS],6228872,CDM,250,RC,59316-0102-12,NDC,,,Outpatient,89,EA,27.9,,,,80,,22.32,percent of total billed charges,,,,85,23.72,percent of total billed charges,,,77.7,,21.68,percent of total billed charges,,,95,,26.51,percent of total billed charges,,,60,,16.74,percent of total billed charges,,16.74,26.51,
menthol topical 4% Gel 89 mL [KHKS],6228872,CDM,250,RC,59316-0102-12,NDC,,,Inpatient,89,EA,27.9,,,,80,,22.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,21.68,percent of total billed charges,,,95,,26.51,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,26.51,
acetaminophen 500 mg Oral Tab [KHKS],6228886,CDM,250,RC,62011-0023-03,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
acetaminophen 500 mg Oral Tab [KHKS],6228886,CDM,250,RC,62011-0023-03,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
budesonide 0.25 mg/2 mL INH Susp [KHKS],6228931,CDM,250,RC,16714-0018-30,NDC,,,Outpatient,2,ML,28.08,,,,80,,22.46,percent of total billed charges,,,,85,23.87,percent of total billed charges,,,77.7,,21.82,percent of total billed charges,,,95,,26.67,percent of total billed charges,,,60,,16.85,percent of total billed charges,,16.85,26.67,
budesonide 0.25 mg/2 mL INH Susp [KHKS],6228931,CDM,250,RC,16714-0018-30,NDC,,,Inpatient,2,ML,28.08,,,,80,,22.46,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,21.82,percent of total billed charges,,,95,,26.67,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,26.67,
zoledronic acid (Reclast) 5 mg/100 mL IV Sol Vial [KHKS],6232093,CDM,636,RC,J3489,HCPCS,55111-0688-52,NDC,Outpatient,100,ML,666,,,,80,,532.8,percent of total billed charges,,,,50,7.17,fee schedule,,,77.7,,517.48,percent of total billed charges,,,95,,632.7,percent of total billed charges,,,60,,399.6,percent of total billed charges,,7.17,632.7,
zoledronic acid (Reclast) 5 mg/100 mL IV Sol Vial [KHKS],6232093,CDM,636,RC,J3489,HCPCS,55111-0688-52,NDC,Inpatient,100,ML,666,,,,80,,532.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,517.48,percent of total billed charges,,,95,,632.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,632.7,
ARIPiprazole 5 mg Tab [KHKS],6232099,CDM,250,RC,50268-0088-15,NDC,,,Outpatient,1,EA,89.78,,,,80,,71.82,percent of total billed charges,,,,85,76.31,percent of total billed charges,,,77.7,,69.76,percent of total billed charges,,,95,,85.29,percent of total billed charges,,,60,,53.87,percent of total billed charges,,53.87,85.29,
ARIPiprazole 5 mg Tab [KHKS],6232099,CDM,250,RC,50268-0088-15,NDC,,,Inpatient,1,EA,89.78,,,,80,,71.82,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,69.76,percent of total billed charges,,,95,,85.29,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,85.29,
amoxicillin 400 mg/5 mL Oral Liq 75 mL [KHKS],6242809,CDM,250,RC,00143-9887-75,NDC,,,Outpatient,75,ML,21.99,,,,80,,17.59,percent of total billed charges,,,,85,18.69,percent of total billed charges,,,77.7,,17.09,percent of total billed charges,,,95,,20.89,percent of total billed charges,,,60,,13.19,percent of total billed charges,,13.19,20.89,
amoxicillin 400 mg/5 mL Oral Liq 75 mL [KHKS],6242809,CDM,250,RC,00143-9887-75,NDC,,,Inpatient,75,ML,21.99,,,,80,,17.59,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,17.09,percent of total billed charges,,,95,,20.89,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,20.89,
amoxicillin 400 mg/5 mL Oral Liq 100 mL [KHKS],6242810,CDM,250,RC,00143-9887-01,NDC,,,Outpatient,100,ML,29.43,,,,80,,23.54,percent of total billed charges,,,,85,25.02,percent of total billed charges,,,77.7,,22.87,percent of total billed charges,,,95,,27.96,percent of total billed charges,,,60,,17.66,percent of total billed charges,,17.66,27.96,
amoxicillin 400 mg/5 mL Oral Liq 100 mL [KHKS],6242810,CDM,250,RC,00143-9887-01,NDC,,,Inpatient,100,ML,29.43,,,,80,,23.54,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,22.87,percent of total billed charges,,,95,,27.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,27.96,
THP AMOXCILLIN-CLAVULANATE (Augmentin) 875 mg-125 mg #4 [KHKS],6262249,CDM,253,RC,16714-0478-02QQ,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
THP AMOXCILLIN-CLAVULANATE (Augmentin) 875 mg-125 mg #4 [KHKS],6262249,CDM,253,RC,16714-0478-02QQ,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
diphenhydrAMINE 12.5 mg/5 mL Oral Liq 120 mL [KHKS],6264435,CDM,250,RC,58657-0528-04,NDC,,,Outpatient,5,ML,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
diphenhydrAMINE 12.5 mg/5 mL Oral Liq 120 mL [KHKS],6264435,CDM,250,RC,58657-0528-04,NDC,,,Inpatient,5,ML,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
"epoetin alfa 40,000 units/mL (Procrit) PF Inj Sol 1mL [KHKS]",6264485,CDM,636,RC,J0885,HCPCS,59676-0340-01,NDC,Outpatient,1,ML,2373.18,,,,80,,1898.54,percent of total billed charges,,,,50,5.31,fee schedule,,,77.7,,1843.96,percent of total billed charges,,,95,,2254.52,percent of total billed charges,,,60,,1423.91,percent of total billed charges,,5.31,2254.52,
"epoetin alfa 40,000 units/mL (Procrit) PF Inj Sol 1mL [KHKS]",6264485,CDM,636,RC,J0885,HCPCS,59676-0340-01,NDC,Inpatient,1,ML,2373.18,,,,80,,1898.54,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1843.96,percent of total billed charges,,,95,,2254.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2254.52,
acetaminophen 325 mg Tab [KHKS],6264493,CDM,250,RC,00536-1327-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
acetaminophen 325 mg Tab [KHKS],6264493,CDM,250,RC,00536-1327-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
budesonide 0.5 mg/2 mL Inh Susp [KHKS],6264641,CDM,250,RC,16714-0019-30,NDC,,,Outpatient,1,ML,16.56,,,,80,,13.25,percent of total billed charges,,,,85,14.08,percent of total billed charges,,,77.7,,12.87,percent of total billed charges,,,95,,15.73,percent of total billed charges,,,60,,9.94,percent of total billed charges,,9.94,15.73,
budesonide 0.5 mg/2 mL Inh Susp [KHKS],6264641,CDM,250,RC,16714-0019-30,NDC,,,Inpatient,1,ML,16.56,,,,80,,13.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.87,percent of total billed charges,,,95,,15.73,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.73,
protamine 10 mg/mL Inj Sol 5 mL [KHKS],6264642,CDM,636,RC,J2720,HCPCS,63323-0229-05,NDC,Outpatient,5,ML,55.73,,,,80,,44.58,percent of total billed charges,,,,50,0.66,fee schedule,,,77.7,,43.3,percent of total billed charges,,,95,,52.94,percent of total billed charges,,,60,,33.44,percent of total billed charges,,0.66,52.94,
protamine 10 mg/mL Inj Sol 5 mL [KHKS],6264642,CDM,636,RC,J2720,HCPCS,63323-0229-05,NDC,Inpatient,5,ML,55.73,,,,80,,44.58,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,43.3,percent of total billed charges,,,95,,52.94,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,52.94,
glycerin adult Supp [KHKS],6264648,CDM,250,RC,00132-0079-12,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
glycerin adult Supp [KHKS],6264648,CDM,250,RC,00132-0079-12,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
carbidopa-levodopa 25 mg-100 mg Tab [KHKS],6264650,CDM,250,RC,71205-0878-90,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
carbidopa-levodopa 25 mg-100 mg Tab [KHKS],6264650,CDM,250,RC,71205-0878-90,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
fluconazole 100 mg Tab [KHKS],6264651,CDM,250,RC,16714-0691-01,NDC,,,Outpatient,1,EA,26.31,,,,80,,21.05,percent of total billed charges,,,,85,22.36,percent of total billed charges,,,77.7,,20.44,percent of total billed charges,,,95,,24.99,percent of total billed charges,,,60,,15.79,percent of total billed charges,,15.79,24.99,
fluconazole 100 mg Tab [KHKS],6264651,CDM,250,RC,16714-0691-01,NDC,,,Inpatient,1,EA,26.31,,,,80,,21.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,20.44,percent of total billed charges,,,95,,24.99,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,24.99,
dantrolene 20 mg IV Inj [KHKS],6264660,CDM,250,RC,42023-0123-06,NDC,,,Outpatient,1,EA,239.33,,,,80,,191.46,percent of total billed charges,,,,85,203.43,percent of total billed charges,,,77.7,,185.96,percent of total billed charges,,,95,,227.36,percent of total billed charges,,,60,,143.6,percent of total billed charges,,143.6,227.36,
dantrolene 20 mg IV Inj [KHKS],6264660,CDM,250,RC,42023-0123-06,NDC,,,Inpatient,1,EA,239.33,,,,80,,191.46,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,185.96,percent of total billed charges,,,95,,227.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,227.36,
lidocaine 1% 10 mg/mL Sol 20 mL Vial MDV [KHKS],6264662,CDM,636,RC,J2003,HCPCS,00409-4276-01,NDC,Outpatient,20,ML,5.71,,,,80,,4.57,percent of total billed charges,,,,85,4.85,percent of total billed charges,,,77.7,,4.44,percent of total billed charges,,,95,,5.42,percent of total billed charges,,,60,,3.43,percent of total billed charges,,3.43,5.42,
lidocaine 1% 10 mg/mL Sol 20 mL Vial MDV [KHKS],6264662,CDM,636,RC,J2003,HCPCS,00409-4276-01,NDC,Inpatient,20,ML,5.71,,,,80,,4.57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.44,percent of total billed charges,,,95,,5.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.42,
lidocaine 1% Inj Sol 10 mL Vial MDV [KHKS],6264663,CDM,636,RC,J2003,HCPCS,63323-0201-10,NDC,Outpatient,10,ML,8.78,,,,80,,7.03,percent of total billed charges,,,,85,7.46,percent of total billed charges,,,77.7,,6.83,percent of total billed charges,,,95,,8.34,percent of total billed charges,,,60,,5.27,percent of total billed charges,,5.27,8.34,
lidocaine 1% Inj Sol 10 mL Vial MDV [KHKS],6264663,CDM,636,RC,J2003,HCPCS,63323-0201-10,NDC,Inpatient,10,ML,8.78,,,,80,,7.03,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.83,percent of total billed charges,,,95,,8.34,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,8.34,
acetylcysteine 20% Inh Sol 30 mL [KHKS],6264664,CDM,250,RC,63323-0690-30,NDC,,,Outpatient,30,ML,82.15,,,,80,,65.72,percent of total billed charges,,,,85,69.83,percent of total billed charges,,,77.7,,63.83,percent of total billed charges,,,95,,78.04,percent of total billed charges,,,60,,49.29,percent of total billed charges,,49.29,78.04,
acetylcysteine 20% Inh Sol 30 mL [KHKS],6264664,CDM,250,RC,63323-0690-30,NDC,,,Inpatient,30,ML,82.15,,,,80,,65.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,63.83,percent of total billed charges,,,95,,78.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,78.04,
fludrocortisone 0.1 mg Tab [KHKS],6264665,CDM,250,RC,68084-0288-01,NDC,,,Outpatient,1,EA,3.16,,,,80,,2.53,percent of total billed charges,,,,85,2.69,percent of total billed charges,,,77.7,,2.46,percent of total billed charges,,,95,,3.01,percent of total billed charges,,,60,,1.9,percent of total billed charges,,1.9,3.01,
fludrocortisone 0.1 mg Tab [KHKS],6264665,CDM,250,RC,68084-0288-01,NDC,,,Inpatient,1,EA,3.16,,,,80,,2.53,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.46,percent of total billed charges,,,95,,3.01,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.01,
octreotide 100 mcg/mL Inj Sol 1 mL [KHKS],6264671,CDM,636,RC,J2354,HCPCS,63323-0376-01,NDC,Outpatient,1,ML,35.78,,,,80,,28.63,percent of total billed charges,,,,50,0.91,fee schedule,,,77.7,,27.8,percent of total billed charges,,,95,,33.99,percent of total billed charges,,,60,,21.47,percent of total billed charges,,0.91,33.99,
octreotide 100 mcg/mL Inj Sol 1 mL [KHKS],6264671,CDM,636,RC,J2354,HCPCS,63323-0376-01,NDC,Inpatient,1,ML,35.78,,,,80,,28.63,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,27.8,percent of total billed charges,,,95,,33.99,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,33.99,
desflurane 100% Inh Liq 240 mL [KHKS],6264672,CDM,250,RC,10019-0644-34,NDC,,,Outpatient,12,ML,28.84,,,,80,,23.07,percent of total billed charges,,,,85,24.51,percent of total billed charges,,,77.7,,22.41,percent of total billed charges,,,95,,27.4,percent of total billed charges,,,60,,17.3,percent of total billed charges,,17.3,27.4,
desflurane 100% Inh Liq 240 mL [KHKS],6264672,CDM,250,RC,10019-0644-34,NDC,,,Inpatient,12,ML,28.84,,,,80,,23.07,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,22.41,percent of total billed charges,,,95,,27.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,27.4,
epinephrine-lidocaine 1:100000-2% Inj Sol 20 mL [KHKS],6264685,CDM,636,RC,J2004,HCPCS,63323-0483-27,NDC,Outpatient,20,ML,15.73,,,,80,,12.59,percent of total billed charges,,,,85,13.37,percent of total billed charges,,,77.7,,12.22,percent of total billed charges,,,95,,14.95,percent of total billed charges,,,60,,9.44,percent of total billed charges,,9.44,14.95,
epinephrine-lidocaine 1:100000-2% Inj Sol 20 mL [KHKS],6264685,CDM,636,RC,J2004,HCPCS,63323-0483-27,NDC,Inpatient,20,ML,15.73,,,,80,,12.59,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.22,percent of total billed charges,,,95,,14.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,14.95,
hepatitis B immune globulin IM Sol 0.5 mL [KHKS],6264687,CDM,636,RC,90371,CPT,13533-0636-03,NDC,Outpatient,0.5,ML,262.56,,,,80,,210.05,percent of total billed charges,,,,50,84.12,fee schedule,,,77.7,,204.01,percent of total billed charges,,,95,,249.43,percent of total billed charges,,,60,,157.54,percent of total billed charges,,157.54,249.43,
hepatitis B immune globulin IM Sol 0.5 mL [KHKS],6264687,CDM,636,RC,90371,CPT,13533-0636-03,NDC,Inpatient,0.5,ML,262.56,,,,80,,210.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,204.01,percent of total billed charges,,,95,,249.43,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,249.43,
"epinephrine-lidocaine 1:200,000-1% PF Inj Sol 30 mL [KHKS]",6264756,CDM,636,RC,J2004,HCPCS,63323-0487-37,NDC,Outpatient,30,ML,42.59,,,,80,,34.07,percent of total billed charges,,,,85,36.2,percent of total billed charges,,,77.7,,33.09,percent of total billed charges,,,95,,40.46,percent of total billed charges,,,60,,25.55,percent of total billed charges,,25.55,40.46,
"epinephrine-lidocaine 1:200,000-1% PF Inj Sol 30 mL [KHKS]",6264756,CDM,636,RC,J2004,HCPCS,63323-0487-37,NDC,Inpatient,30,ML,42.59,,,,80,,34.07,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,33.09,percent of total billed charges,,,95,,40.46,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,40.46,
fentaNYL 50 mcg/mL Inj Sol 5 mL [KHKS],6265212,CDM,636,RC,J3010,HCPCS,00409-9094-25,NDC,Outpatient,5,ML,7.56,,,,80,,6.05,percent of total billed charges,,,,50,0.59,fee schedule,,,77.7,,5.87,percent of total billed charges,,,95,,7.18,percent of total billed charges,,,60,,4.54,percent of total billed charges,,0.59,7.18,
fentaNYL 50 mcg/mL Inj Sol 5 mL [KHKS],6265212,CDM,636,RC,J3010,HCPCS,00409-9094-25,NDC,Inpatient,5,ML,7.56,,,,80,,6.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.87,percent of total billed charges,,,95,,7.18,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.18,
methylene blue 5 mg/mL Sol 10 mL [KHKS],6265394,CDM,636,RC,Q9968,HCPCS,00517-0374-05,NDC,Outpatient,10,ML,578.15,,,,80,,462.52,percent of total billed charges,,,,85,491.43,percent of total billed charges,,,77.7,,449.23,percent of total billed charges,,,95,,549.25,percent of total billed charges,,,60,,346.89,percent of total billed charges,,346.89,549.25,
methylene blue 5 mg/mL Sol 10 mL [KHKS],6265394,CDM,636,RC,Q9968,HCPCS,00517-0374-05,NDC,Inpatient,10,ML,578.15,,,,80,,462.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,449.23,percent of total billed charges,,,95,,549.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,549.25,
insulin degludec 100 units/mL Sol 10 mL Vial [KHKS],6265395,CDM,636,RC,J1815,HCPCS,00169-2662-11,NDC,Outpatient,1,ML,122.02,,,,80,,97.62,percent of total billed charges,,,,50,0.58,fee schedule,,,77.7,,94.81,percent of total billed charges,,,95,,115.92,percent of total billed charges,,,60,,73.21,percent of total billed charges,,0.58,115.92,
insulin degludec 100 units/mL Sol 10 mL Vial [KHKS],6265395,CDM,636,RC,J1815,HCPCS,00169-2662-11,NDC,Inpatient,1,ML,122.02,,,,80,,97.62,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,94.81,percent of total billed charges,,,95,,115.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,115.92,
cilostazol 50 mg Tab [KHKS],6265416,CDM,250,RC,50268-0176-15,NDC,,,Outpatient,1,EA,6.7,,,,80,,5.36,percent of total billed charges,,,,85,5.7,percent of total billed charges,,,77.7,,5.2,percent of total billed charges,,,95,,6.36,percent of total billed charges,,,60,,4.02,percent of total billed charges,,4.02,6.36,
cilostazol 50 mg Tab [KHKS],6265416,CDM,250,RC,50268-0176-15,NDC,,,Inpatient,1,EA,6.7,,,,80,,5.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.2,percent of total billed charges,,,95,,6.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.36,
"typhoid vaccine, inactivated Inj Sol 0.5 mL [KHKS]",6265417,CDM,636,RC,90691,CPT,49281-0790-51,NDC,Outpatient,0.5,ML,329.92,,,,80,,263.93,percent of total billed charges,,,,50,57.33,fee schedule,,,77.7,,256.35,percent of total billed charges,,,95,,313.42,percent of total billed charges,,,60,,197.95,percent of total billed charges,,197.95,313.42,
"typhoid vaccine, inactivated Inj Sol 0.5 mL [KHKS]",6265417,CDM,636,RC,90691,CPT,49281-0790-51,NDC,Inpatient,0.5,ML,329.92,,,,80,,263.93,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,256.35,percent of total billed charges,,,95,,313.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,313.42,
hydrocortisone 100 mg preservative-free Pow-Inj Vial [KHKS],6265418,CDM,636,RC,J1720,HCPCS,00009-0011-03,NDC,Outpatient,1,EA,66.6,,,,80,,53.28,percent of total billed charges,,,,50,11.35,fee schedule,,,77.7,,51.75,percent of total billed charges,,,95,,63.27,percent of total billed charges,,,60,,39.96,percent of total billed charges,,11.35,63.27,
hydrocortisone 100 mg preservative-free Pow-Inj Vial [KHKS],6265418,CDM,636,RC,J1720,HCPCS,00009-0011-03,NDC,Inpatient,1,EA,66.6,,,,80,,53.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,51.75,percent of total billed charges,,,95,,63.27,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,63.27,
epinephrine-lidocaine 1:100000-1% Inj Sol 20 mL MDV [KHKS],6265574,CDM,636,RC,J2004,HCPCS,63323-0482-27,NDC,Outpatient,20,ML,15.52,,,,80,,12.41,percent of total billed charges,,,,85,13.19,percent of total billed charges,,,77.7,,12.06,percent of total billed charges,,,95,,14.74,percent of total billed charges,,,60,,9.31,percent of total billed charges,,9.31,14.74,
epinephrine-lidocaine 1:100000-1% Inj Sol 20 mL MDV [KHKS],6265574,CDM,636,RC,J2004,HCPCS,63323-0482-27,NDC,Inpatient,20,ML,15.52,,,,80,,12.41,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.06,percent of total billed charges,,,95,,14.74,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,14.74,
fat emulsion 20% IV 250 mL [KHKS],6265575,CDM,250,RC,00264-4460-30,NDC,,,Outpatient,250,ML,84.82,,,,80,,67.85,percent of total billed charges,,,,85,72.1,percent of total billed charges,,,77.7,,65.9,percent of total billed charges,,,95,,80.58,percent of total billed charges,,,60,,50.89,percent of total billed charges,,50.89,80.58,
fat emulsion 20% IV 250 mL [KHKS],6265575,CDM,250,RC,00264-4460-30,NDC,,,Inpatient,250,ML,84.82,,,,80,,67.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,65.9,percent of total billed charges,,,95,,80.58,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,80.58,
lidocaine-prilocaine Top 2.5%-2.5% Cream 5 gm [KHKS],6265577,CDM,250,RC,00168-0357-55,NDC,,,Outpatient,5,EA,29.75,,,,80,,23.8,percent of total billed charges,,,,85,25.29,percent of total billed charges,,,77.7,,23.11,percent of total billed charges,,,95,,28.26,percent of total billed charges,,,60,,17.85,percent of total billed charges,,17.85,28.26,
lidocaine-prilocaine Top 2.5%-2.5% Cream 5 gm [KHKS],6265577,CDM,250,RC,00168-0357-55,NDC,,,Inpatient,5,EA,29.75,,,,80,,23.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,23.11,percent of total billed charges,,,95,,28.26,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,28.26,
amLODIPine 5 mg Tab,6280707,CDM,250,RC,00904-6370-61,NDC,,,Outpatient,1,EA,4.93,,,,80,,3.94,percent of total billed charges,,,,85,4.19,percent of total billed charges,,,77.7,,3.83,percent of total billed charges,,,95,,4.68,percent of total billed charges,,,60,,2.96,percent of total billed charges,,2.96,4.68,
amLODIPine 5 mg Tab,6280707,CDM,250,RC,00904-6370-61,NDC,,,Inpatient,1,EA,4.93,,,,80,,3.94,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.83,percent of total billed charges,,,95,,4.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.68,
ampicillin-sulbactam 3 g Inj Pow [KHKS],6280715,CDM,636,RC,J0295,HCPCS,70594-0082-02,NDC,Outpatient,1,EA,32.4,,,,80,,25.92,percent of total billed charges,,,,50,1.44,fee schedule,,,77.7,,25.17,percent of total billed charges,,,95,,30.78,percent of total billed charges,,,60,,19.44,percent of total billed charges,,1.44,30.78,
ampicillin-sulbactam 3 g Inj Pow [KHKS],6280715,CDM,636,RC,J0295,HCPCS,70594-0082-02,NDC,Inpatient,1,EA,32.4,,,,80,,25.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,25.17,percent of total billed charges,,,95,,30.78,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,30.78,
ampicillin-sulbactam 1.5 gm Inj Powd [KHKS],6280725,CDM,636,RC,J0295,HCPCS,66794-0206-41,NDC,Outpatient,1,EA,15.48,,,,80,,12.38,percent of total billed charges,,,,50,1.44,fee schedule,,,77.7,,12.03,percent of total billed charges,,,95,,14.71,percent of total billed charges,,,60,,9.29,percent of total billed charges,,1.44,14.71,
ampicillin-sulbactam 1.5 gm Inj Powd [KHKS],6280725,CDM,636,RC,J0295,HCPCS,66794-0206-41,NDC,Inpatient,1,EA,15.48,,,,80,,12.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.03,percent of total billed charges,,,95,,14.71,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,14.71,
ipratropium 0.5 mg/2.5 mL (0.02%) INH Sol 2.5 mL [KHKS],6280729,CDM,250,RC,00378-7970-52,NDC,,,Outpatient,2.5,ML,5.7,,,,80,,4.56,percent of total billed charges,,,,85,4.85,percent of total billed charges,,,77.7,,4.43,percent of total billed charges,,,95,,5.42,percent of total billed charges,,,60,,3.42,percent of total billed charges,,3.42,5.42,
ipratropium 0.5 mg/2.5 mL (0.02%) INH Sol 2.5 mL [KHKS],6280729,CDM,250,RC,00378-7970-52,NDC,,,Inpatient,2.5,ML,5.7,,,,80,,4.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.43,percent of total billed charges,,,95,,5.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.42,
acetaminophen 500 mg Oral Tab [KHKS],6280730,CDM,250,RC,00904-6730-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
acetaminophen 500 mg Oral Tab [KHKS],6280730,CDM,250,RC,00904-6730-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
aspirin 325 mg Oral EC Tab [KHKS],6280731,CDM,250,RC,57896-0921-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
aspirin 325 mg Oral EC Tab [KHKS],6280731,CDM,250,RC,57896-0921-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
atenolol 25 mg Tab [KHKS],6280732,CDM,250,RC,00904-7187-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
atenolol 25 mg Tab [KHKS],6280732,CDM,250,RC,00904-7187-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
azithromycin 250 mg Tab [KHKS],6280733,CDM,250,RC,00904-6708-06,NDC,,,Outpatient,1,EA,4.45,,,,80,,3.56,percent of total billed charges,,,,85,3.78,percent of total billed charges,,,77.7,,3.45,percent of total billed charges,,,95,,4.22,percent of total billed charges,,,60,,2.67,percent of total billed charges,,2.67,4.22,
azithromycin 250 mg Tab [KHKS],6280733,CDM,250,RC,00904-6708-06,NDC,,,Inpatient,1,EA,4.45,,,,80,,3.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.45,percent of total billed charges,,,95,,4.22,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.22,
benazepril 10 mg Tab [KHKS],6280734,CDM,250,RC,50268-0110-15,NDC,,,Outpatient,1,EA,2.83,,,,80,,2.26,percent of total billed charges,,,,85,2.41,percent of total billed charges,,,77.7,,2.2,percent of total billed charges,,,95,,2.69,percent of total billed charges,,,60,,1.7,percent of total billed charges,,1.7,2.69,
benazepril 10 mg Tab [KHKS],6280734,CDM,250,RC,50268-0110-15,NDC,,,Inpatient,1,EA,2.83,,,,80,,2.26,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.2,percent of total billed charges,,,95,,2.69,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.69,
betamethasone acetate-betamethasone sodium phosphate 3 mg-3 mg Inj Susp 5 mL [KHKS],6280737,CDM,636,RC,J0702,HCPCS,78206-0118-01,NDC,Outpatient,5,ML,149.69,,,,80,,119.75,percent of total billed charges,,,,50,4.38,fee schedule,,,77.7,,116.31,percent of total billed charges,,,95,,142.2,percent of total billed charges,,,60,,89.81,percent of total billed charges,,4.38,142.2,
betamethasone acetate-betamethasone sodium phosphate 3 mg-3 mg Inj Susp 5 mL [KHKS],6280737,CDM,636,RC,J0702,HCPCS,78206-0118-01,NDC,Inpatient,5,ML,149.69,,,,80,,119.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,116.31,percent of total billed charges,,,95,,142.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,142.2,
bumetanide 0.25 mg/mL Inj Sol 4 mL [KHKS],6280738,CDM,636,RC,00641-6008-10,NDC,,,Outpatient,4,ML,10.87,,,,80,,8.7,percent of total billed charges,,,,85,9.24,percent of total billed charges,,,77.7,,8.45,percent of total billed charges,,,95,,10.33,percent of total billed charges,,,60,,6.52,percent of total billed charges,,6.52,10.33,
bumetanide 0.25 mg/mL Inj Sol 4 mL [KHKS],6280738,CDM,636,RC,00641-6008-10,NDC,,,Inpatient,4,ML,10.87,,,,80,,8.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.45,percent of total billed charges,,,95,,10.33,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.33,
ceFAZolin 1 g Inj [KHKS],6280746,CDM,636,RC,J0690,HCPCS,00143-9262-25,NDC,Outpatient,1,EA,3.79,,,,80,,3.03,percent of total billed charges,,,,50,0.55,fee schedule,,,77.7,,2.94,percent of total billed charges,,,95,,3.6,percent of total billed charges,,,60,,2.27,percent of total billed charges,,0.55,3.6,
ceFAZolin 1 g Inj [KHKS],6280746,CDM,636,RC,J0690,HCPCS,00143-9262-25,NDC,Inpatient,1,EA,3.79,,,,80,,3.03,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.94,percent of total billed charges,,,95,,3.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.6,
carbidopa-levodopa 10 mg-100 mg Tab [KHKS],6280749,CDM,250,RC,00093-9701-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
carbidopa-levodopa 10 mg-100 mg Tab [KHKS],6280749,CDM,250,RC,00093-9701-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
glucose 50% IV Sol 50 mL [KHKS],6280785,CDM,250,RC,76329-3302-01,NDC,,,Outpatient,50,ML,60.34,,,,80,,48.27,percent of total billed charges,,,,85,51.29,percent of total billed charges,,,77.7,,46.88,percent of total billed charges,,,95,,57.32,percent of total billed charges,,,60,,36.2,percent of total billed charges,,36.2,57.32,
glucose 50% IV Sol 50 mL [KHKS],6280785,CDM,250,RC,76329-3302-01,NDC,,,Inpatient,50,ML,60.34,,,,80,,48.27,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,46.88,percent of total billed charges,,,95,,57.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,57.32,
oxytocin 10 units/mL Inj Sol 1 mL [KHKS],6280786,CDM,636,RC,J2590,HCPCS,63323-0012-07,NDC,Outpatient,1,ML,5.4,,,,80,,4.32,percent of total billed charges,,,,50,0.53,fee schedule,,,77.7,,4.2,percent of total billed charges,,,95,,5.13,percent of total billed charges,,,60,,3.24,percent of total billed charges,,0.53,5.13,
oxytocin 10 units/mL Inj Sol 1 mL [KHKS],6280786,CDM,636,RC,J2590,HCPCS,63323-0012-07,NDC,Inpatient,1,ML,5.4,,,,80,,4.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.2,percent of total billed charges,,,95,,5.13,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.13,
metroNIDAZOLE 500 mg/100 mL IV Sol [KHKS],6280787,CDM,636,RC,J1836,HCPCS,00409-0152-24,NDC,Outpatient,100,ML,6.91,,,,80,,5.53,percent of total billed charges,,,,85,5.87,percent of total billed charges,,,77.7,,5.37,percent of total billed charges,,,95,,6.57,percent of total billed charges,,,60,,4.15,percent of total billed charges,,4.15,6.57,
metroNIDAZOLE 500 mg/100 mL IV Sol [KHKS],6280787,CDM,636,RC,J1836,HCPCS,00409-0152-24,NDC,Inpatient,100,ML,6.91,,,,80,,5.53,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.37,percent of total billed charges,,,95,,6.57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.57,
ciprofloxacin-dexamethasone otic 0.3%-0.1% Sus,6280793,CDM,16714-0628-01,NDC,,,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
ciprofloxacin-dexamethasone otic 0.3%-0.1% Sus,6280793,CDM,16714-0628-01,NDC,,,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
clindamycin 150 mg/mL IV Sol 6 mL [KHKS],6280796,CDM,636,RC,J7036,HCPCS,25021-0115-06,NDC,Outpatient,6,ML,17.1,,,,80,,13.68,percent of total billed charges,,,,85,14.54,percent of total billed charges,,,77.7,,13.29,percent of total billed charges,,,95,,16.25,percent of total billed charges,,,60,,10.26,percent of total billed charges,,10.26,16.25,
clindamycin 150 mg/mL IV Sol 6 mL [KHKS],6280796,CDM,636,RC,J7036,HCPCS,25021-0115-06,NDC,Inpatient,6,ML,17.1,,,,80,,13.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,13.29,percent of total billed charges,,,95,,16.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,16.25,
lidocaine 2% 20 mg/mL Inj Sol 10 mL [KHKS],6280797,CDM,J2003,HCPCS,55150-0254-10,NDC,,,Outpatient,10,ML,13.68,,,,80,,10.94,percent of total billed charges,,,,85,11.63,percent of total billed charges,,,77.7,,10.63,percent of total billed charges,,,95,,13,percent of total billed charges,,,60,,8.21,percent of total billed charges,,8.21,13,
lidocaine 2% 20 mg/mL Inj Sol 10 mL [KHKS],6280797,CDM,J2003,HCPCS,55150-0254-10,NDC,,,Inpatient,10,ML,13.68,,,,80,,10.94,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.63,percent of total billed charges,,,95,,13,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13,
tranexamic acid 100 mg/mL IV Sol 10 mL [KHKS],6280810,CDM,250,RC,55150-0188-10,NDC,,,Outpatient,10,ML,21.6,,,,80,,17.28,percent of total billed charges,,,,85,18.36,percent of total billed charges,,,77.7,,16.78,percent of total billed charges,,,95,,20.52,percent of total billed charges,,,60,,12.96,percent of total billed charges,,12.96,20.52,
tranexamic acid 100 mg/mL IV Sol 10 mL [KHKS],6280810,CDM,250,RC,55150-0188-10,NDC,,,Inpatient,10,ML,21.6,,,,80,,17.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,16.78,percent of total billed charges,,,95,,20.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,20.52,
sucralfate 1 g Tab [KHKS],6280812,CDM,250,RC,51079-0753-20,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
sucralfate 1 g Tab [KHKS],6280812,CDM,250,RC,51079-0753-20,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
simethicone 80 mg Tab,6280814,CDM,250,RC,77333-0812-10,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
simethicone 80 mg Tab,6280814,CDM,250,RC,77333-0812-10,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
nitrofurantoin macrocrystals-monohydrate 100 mg Cap [KHKS],6280817,CDM,250,RC,60687-0633-01,NDC,,,Outpatient,1,EA,10.59,,,,80,,8.47,percent of total billed charges,,,,85,9,percent of total billed charges,,,77.7,,8.23,percent of total billed charges,,,95,,10.06,percent of total billed charges,,,60,,6.35,percent of total billed charges,,6.35,10.06,
nitrofurantoin macrocrystals-monohydrate 100 mg Cap [KHKS],6280817,CDM,250,RC,60687-0633-01,NDC,,,Inpatient,1,EA,10.59,,,,80,,8.47,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.23,percent of total billed charges,,,95,,10.06,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.06,
DULoxetine 30 mg Cap [KHKS],6280819,CDM,250,RC,57237-0018-30,NDC,,,Outpatient,1,EA,23.56,,,,80,,18.84,percent of total billed charges,,,,85,20.03,percent of total billed charges,,,77.7,,18.3,percent of total billed charges,,,95,,22.38,percent of total billed charges,,,60,,14.13,percent of total billed charges,,14.13,22.38,
DULoxetine 30 mg Cap [KHKS],6280819,CDM,250,RC,57237-0018-30,NDC,,,Inpatient,1,EA,23.56,,,,80,,18.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,18.3,percent of total billed charges,,,95,,22.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,22.38,
ondansetron 2 mg/mL Inj Sol 2 mL [KHKS],6280821,CDM,636,RC,J2405,HCPCS,36000-0012-25,NDC,Outpatient,2,ML,3.3,,,,80,,2.64,percent of total billed charges,,,,50,0.06,fee schedule,,,77.7,,2.57,percent of total billed charges,,,95,,3.14,percent of total billed charges,,,60,,1.98,percent of total billed charges,,0.06,3.14,
ondansetron 2 mg/mL Inj Sol 2 mL [KHKS],6280821,CDM,636,RC,J2405,HCPCS,36000-0012-25,NDC,Inpatient,2,ML,3.3,,,,80,,2.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.57,percent of total billed charges,,,95,,3.14,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.14,
oseltamivir 75 mg Cap [KHKS],6280822,CDM,250,RC,00004-0800-85,NDC,,,Outpatient,1,EA,54.68,,,,80,,43.74,percent of total billed charges,,,,85,46.48,percent of total billed charges,,,77.7,,42.48,percent of total billed charges,,,95,,51.94,percent of total billed charges,,,60,,32.81,percent of total billed charges,,32.81,51.94,
oseltamivir 75 mg Cap [KHKS],6280822,CDM,250,RC,00004-0800-85,NDC,,,Inpatient,1,EA,54.68,,,,80,,43.74,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,42.48,percent of total billed charges,,,95,,51.94,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,51.94,
orphenadrine 30 mg/mL Inj Sol 2 mL [KHKS],6280824,CDM,636,RC,J2360,HCPCS,00641-6182-10,NDC,Outpatient,2,ML,59.7,,,,80,,47.76,percent of total billed charges,,,,50,3.46,fee schedule,,,77.7,,46.39,percent of total billed charges,,,95,,56.72,percent of total billed charges,,,60,,35.82,percent of total billed charges,,3.46,56.72,
orphenadrine 30 mg/mL Inj Sol 2 mL [KHKS],6280824,CDM,636,RC,J2360,HCPCS,00641-6182-10,NDC,Inpatient,2,ML,59.7,,,,80,,47.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,46.39,percent of total billed charges,,,95,,56.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,56.72,
ertapenem 1 g IV Inj Sol[KHKS],6280825,CDM,636,RC,J1335,HCPCS,60505-6196-04,NDC,Outpatient,1,EA,316.09,,,,80,,252.87,percent of total billed charges,,,,50,11.61,fee schedule,,,77.7,,245.6,percent of total billed charges,,,95,,300.28,percent of total billed charges,,,60,,189.65,percent of total billed charges,,11.61,300.28,
ertapenem 1 g IV Inj Sol[KHKS],6280825,CDM,636,RC,J1335,HCPCS,60505-6196-04,NDC,Inpatient,1,EA,316.09,,,,80,,252.87,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,245.6,percent of total billed charges,,,95,,300.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,300.28,
bacitracin topical zinc 500 units/g Oint UD [KHKS],6280826,CDM,250,RC,57896-0145-14,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
bacitracin topical zinc 500 units/g Oint UD [KHKS],6280826,CDM,250,RC,57896-0145-14,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
bacitracin topical zinc 500 units/g Oint UD [KHKS],6280827,CDM,250,RC,00904-7023-67,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
bacitracin topical zinc 500 units/g Oint UD [KHKS],6280827,CDM,250,RC,00904-7023-67,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
escitalopram 10 mg Tab [KHKS],6280829,CDM,250,RC,65862-0374-01,NDC,,,Outpatient,1,EA,14.15,,,,80,,11.32,percent of total billed charges,,,,85,12.03,percent of total billed charges,,,77.7,,10.99,percent of total billed charges,,,95,,13.44,percent of total billed charges,,,60,,8.49,percent of total billed charges,,8.49,13.44,
escitalopram 10 mg Tab [KHKS],6280829,CDM,250,RC,65862-0374-01,NDC,,,Inpatient,1,EA,14.15,,,,80,,11.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.99,percent of total billed charges,,,95,,13.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.44,
famotidine 10 mg Tab [KHKS],6280830,CDM,250,RC,49348-0128-13,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
famotidine 10 mg Tab [KHKS],6280830,CDM,250,RC,49348-0128-13,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
glycopyrrolate 0.2 mg/mL Inj Sol 5 mL MDV [KHKS],6280833,CDM,636,RC,J1596,HCPCS,70121-1396-05,NDC,Outpatient,5,ML,112.45,,,,80,,89.96,percent of total billed charges,,,,85,95.58,percent of total billed charges,,,77.7,,87.38,percent of total billed charges,,,95,,106.83,percent of total billed charges,,,60,,67.47,percent of total billed charges,,67.47,106.83,
glycopyrrolate 0.2 mg/mL Inj Sol 5 mL MDV [KHKS],6280833,CDM,636,RC,J1596,HCPCS,70121-1396-05,NDC,Inpatient,5,ML,112.45,,,,80,,89.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,87.38,percent of total billed charges,,,95,,106.83,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,106.83,
glimepiride 2 mg Tab [KHKS],6280835,CDM,250,RC,55111-0321-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
glimepiride 2 mg Tab [KHKS],6280835,CDM,250,RC,55111-0321-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
labetalol 5 mg/mL IV Sol 20 mL [KHKS],6281083,CDM,636,RC,J1920,HCPCS,00143-9622-01,NDC,Outpatient,1,ML,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
labetalol 5 mg/mL IV Sol 20 mL [KHKS],6281083,CDM,636,RC,J1920,HCPCS,00143-9622-01,NDC,Inpatient,1,ML,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
ketorolac 30 mg/mL Inj Sol 1 mL [KHKS],6281084,CDM,636,RC,J1885,HCPCS,72266-0118-25,NDC,Outpatient,1,ML,15.36,,,,80,,12.29,percent of total billed charges,,,,50,0.38,fee schedule,,,77.7,,11.93,percent of total billed charges,,,95,,14.59,percent of total billed charges,,,60,,9.22,percent of total billed charges,,0.38,14.59,
ketorolac 30 mg/mL Inj Sol 1 mL [KHKS],6281084,CDM,636,RC,J1885,HCPCS,72266-0118-25,NDC,Inpatient,1,ML,15.36,,,,80,,12.29,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.93,percent of total billed charges,,,95,,14.59,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,14.59,
hydrochlorothiazide 12.5 mg Cap [KHKS],6281102,CDM,250,RC,50228-0146-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
hydrochlorothiazide 12.5 mg Cap [KHKS],6281102,CDM,250,RC,50228-0146-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
lisinopril 10 mg Tab [KHKS],6281104,CDM,250,RC,60687-0325-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
lisinopril 10 mg Tab [KHKS],6281104,CDM,250,RC,60687-0325-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
losartan 50 mg Tab [KHKS],6281107,CDM,250,RC,50268-0505-15,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
losartan 50 mg Tab [KHKS],6281107,CDM,250,RC,50268-0505-15,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
enoxaparin 100 mg/mL Sol Syringe [KHKS],6281108,CDM,636,RC,J1650,HCPCS,00955-1010-10,NDC,Outpatient,1,ML,76.93,,,,80,,61.55,percent of total billed charges,,,,50,0.52,fee schedule,,,77.7,,59.78,percent of total billed charges,,,95,,73.09,percent of total billed charges,,,60,,46.16,percent of total billed charges,,0.52,73.09,
enoxaparin 100 mg/mL Sol Syringe [KHKS],6281108,CDM,636,RC,J1650,HCPCS,00955-1010-10,NDC,Inpatient,1,ML,76.93,,,,80,,61.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,59.78,percent of total billed charges,,,95,,73.09,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,73.09,
mirtazapine 15 mg Tab [KHKS],6281109,CDM,250,RC,63739-0098-10,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
mirtazapine 15 mg Tab [KHKS],6281109,CDM,250,RC,63739-0098-10,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
metFORMIN 500 mg Tab [KHKS],6281110,CDM,250,RC,00904-7162-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
metFORMIN 500 mg Tab [KHKS],6281110,CDM,250,RC,00904-7162-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
metoclopramide 10 mg Tab [KHKS],6281111,CDM,250,RC,60687-0631-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
metoclopramide 10 mg Tab [KHKS],6281111,CDM,250,RC,60687-0631-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
misoprostol 100 mcg Tab [KHKS],6281116,CDM,250,RC,70954-0443-10,NDC,,,Outpatient,1,EA,2.94,,,,80,,2.35,percent of total billed charges,,,,85,2.5,percent of total billed charges,,,77.7,,2.28,percent of total billed charges,,,95,,2.79,percent of total billed charges,,,60,,1.76,percent of total billed charges,,1.76,2.79,
misoprostol 100 mcg Tab [KHKS],6281116,CDM,250,RC,70954-0443-10,NDC,,,Inpatient,1,EA,2.94,,,,80,,2.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.28,percent of total billed charges,,,95,,2.79,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.79,
LORazepam 2 mg/mL Inj Sol 1 mL [KHKS],6281117,CDM,636,RC,J2060,HCPCS,00409-1985-30,NDC,Outpatient,1,ML,11.74,,,,80,,9.39,percent of total billed charges,,,,50,0.76,fee schedule,,,77.7,,9.12,percent of total billed charges,,,95,,11.16,percent of total billed charges,,,60,,7.05,percent of total billed charges,,0.76,11.16,
LORazepam 2 mg/mL Inj Sol 1 mL [KHKS],6281117,CDM,636,RC,J2060,HCPCS,00409-1985-30,NDC,Inpatient,1,ML,11.74,,,,80,,9.39,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.12,percent of total billed charges,,,95,,11.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.16,
arformoterol 15 mcg/2 mL Inh Sol [KHKS],6281118,CDM,250,RC,63402-0911-64,NDC,,,Outpatient,2,ML,67.54,,,,80,,54.03,percent of total billed charges,,,,85,57.41,percent of total billed charges,,,77.7,,52.48,percent of total billed charges,,,95,,64.16,percent of total billed charges,,,60,,40.52,percent of total billed charges,,40.52,64.16,
arformoterol 15 mcg/2 mL Inh Sol [KHKS],6281118,CDM,250,RC,63402-0911-64,NDC,,,Inpatient,2,ML,67.54,,,,80,,54.03,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,52.48,percent of total billed charges,,,95,,64.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,64.16,
ePHEDrine 50 mg/mL Sol [KHKS],6281128,CDM,250,RC,43598-0725-25,NDC,,,Outpatient,1,ML,55.44,,,,80,,44.35,percent of total billed charges,,,,85,47.12,percent of total billed charges,,,77.7,,43.08,percent of total billed charges,,,95,,52.67,percent of total billed charges,,,60,,33.26,percent of total billed charges,,33.26,52.67,
ePHEDrine 50 mg/mL Sol [KHKS],6281128,CDM,250,RC,43598-0725-25,NDC,,,Inpatient,1,ML,55.44,,,,80,,44.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,43.08,percent of total billed charges,,,95,,52.67,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,52.67,
fentaNYL 12 mcg/hr Patch [KHKS],6281129,CDM,250,RC,47781-0423-47,NDC,,,Outpatient,1,EA,60.91,,,,80,,48.72,percent of total billed charges,,,,85,51.77,percent of total billed charges,,,77.7,,47.32,percent of total billed charges,,,95,,57.86,percent of total billed charges,,,60,,36.54,percent of total billed charges,,36.54,57.86,
fentaNYL 12 mcg/hr Patch [KHKS],6281129,CDM,250,RC,47781-0423-47,NDC,,,Inpatient,1,EA,60.91,,,,80,,48.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,47.32,percent of total billed charges,,,95,,57.86,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,57.86,
fentaNYL 50 mcg/mL Inj Sol 2mL [KHKS],6281130,CDM,636,RC,J3010,HCPCS,00409-9094-22,NDC,Outpatient,2,ML,5.04,,,,80,,4.03,percent of total billed charges,,,,50,0.59,fee schedule,,,77.7,,3.92,percent of total billed charges,,,95,,4.79,percent of total billed charges,,,60,,3.02,percent of total billed charges,,0.59,4.79,
fentaNYL 50 mcg/mL Inj Sol 2mL [KHKS],6281130,CDM,636,RC,J3010,HCPCS,00409-9094-22,NDC,Inpatient,2,ML,5.04,,,,80,,4.03,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.92,percent of total billed charges,,,95,,4.79,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.79,
LORazepam 0.5 mg Tab [KHKS],6281134,CDM,250,RC,00904-6007-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
LORazepam 0.5 mg Tab [KHKS],6281134,CDM,250,RC,00904-6007-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
morphine 4 mg/mLPF IV Sol 1 mL [KHKS],6281139,CDM,636,RC,J2270,HCPCS,00409-1891-01,NDC,Outpatient,1,ML,7.01,,,,80,,5.6,percent of total billed charges,,,,50,2.15,fee schedule,,,77.7,,5.44,percent of total billed charges,,,95,,6.66,percent of total billed charges,,,60,,4.2,percent of total billed charges,,2.15,6.66,
morphine 4 mg/mLPF IV Sol 1 mL [KHKS],6281139,CDM,636,RC,J2270,HCPCS,00409-1891-01,NDC,Inpatient,1,ML,7.01,,,,80,,5.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.44,percent of total billed charges,,,95,,6.66,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.66,
acetaminophen-oxyCODONE 325 mg-10 mg Tab [KHKS],6281141,CDM,250,RC,00904-7095-61,NDC,,,Outpatient,1,EA,4.31,,,,80,,3.45,percent of total billed charges,,,,85,3.66,percent of total billed charges,,,77.7,,3.35,percent of total billed charges,,,95,,4.1,percent of total billed charges,,,60,,2.59,percent of total billed charges,,2.59,4.1,
acetaminophen-oxyCODONE 325 mg-10 mg Tab [KHKS],6281141,CDM,250,RC,00904-7095-61,NDC,,,Inpatient,1,EA,4.31,,,,80,,3.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.35,percent of total billed charges,,,95,,4.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.1,
Lactated Ringers Injection Sol 1000 mL [KHKS],6282246,CDM,636,RC,J7120,HCPCS,00990-7953-09,NDC,Outpatient,1000,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,50,1.6,fee schedule,,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,60,,11.34,percent of total billed charges,,1.6,17.96,
Lactated Ringers Injection Sol 1000 mL [KHKS],6282246,CDM,636,RC,J7120,HCPCS,00990-7953-09,NDC,Inpatient,1000,ML,18.9,,,,80,,15.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.69,percent of total billed charges,,,95,,17.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.96,
"bupivacaine-epinephrine 0.25%-1:200,000 PF Inj Sol 30 mL [KHKS]",6284536,CDM,250,RC,63323-0468-37,NDC,,,Outpatient,30,ML,35.06,,,,80,,28.05,percent of total billed charges,,,,85,29.8,percent of total billed charges,,,77.7,,27.24,percent of total billed charges,,,95,,33.31,percent of total billed charges,,,60,,21.04,percent of total billed charges,,21.04,33.31,
"bupivacaine-epinephrine 0.25%-1:200,000 PF Inj Sol 30 mL [KHKS]",6284536,CDM,250,RC,63323-0468-37,NDC,,,Inpatient,30,ML,35.06,,,,80,,28.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,27.24,percent of total billed charges,,,95,,33.31,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,33.31,
cefTRIAXone 1 g Inj Vial [KHKS],6284551,CDM,636,RC,J0696,HCPCS,00409-7332-20,NDC,Outpatient,1,EA,5.48,,,,80,,4.39,percent of total billed charges,,,,50,0.4,fee schedule,,,77.7,,4.26,percent of total billed charges,,,95,,5.21,percent of total billed charges,,,60,,3.29,percent of total billed charges,,0.4,5.21,
cefTRIAXone 1 g Inj Vial [KHKS],6284551,CDM,636,RC,J0696,HCPCS,00409-7332-20,NDC,Inpatient,1,EA,5.48,,,,80,,4.39,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.26,percent of total billed charges,,,95,,5.21,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.21,
cefTRIAXone 1 g Inj Vial [KHKS],6284552,CDM,636,RC,J0696,HCPCS,60505-6148-04,NDC,Outpatient,1,EA,137.85,,,,80,,110.28,percent of total billed charges,,,,50,0.4,fee schedule,,,77.7,,107.11,percent of total billed charges,,,95,,130.95,percent of total billed charges,,,60,,82.71,percent of total billed charges,,0.4,130.95,
cefTRIAXone 1 g Inj Vial [KHKS],6284552,CDM,636,RC,J0696,HCPCS,60505-6148-04,NDC,Inpatient,1,EA,137.85,,,,80,,110.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,107.11,percent of total billed charges,,,95,,130.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,130.95,
cephalexin 250 mg/5 mL Oral Liq 200 mL [KHKS],6284556,CDM,250,RC,68180-0441-02,NDC,,,Outpatient,200,ML,153.75,,,,80,,123,percent of total billed charges,,,,85,130.69,percent of total billed charges,,,77.7,,119.46,percent of total billed charges,,,95,,146.06,percent of total billed charges,,,60,,92.25,percent of total billed charges,,92.25,146.06,
cephalexin 250 mg/5 mL Oral Liq 200 mL [KHKS],6284556,CDM,250,RC,68180-0441-02,NDC,,,Inpatient,200,ML,153.75,,,,80,,123,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,119.46,percent of total billed charges,,,95,,146.06,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,146.06,
polyethylene glycol 3350 Oral Pwdr for Recon 238 gm [KHKS],6284571,CDM,250,RC,11523-7234-03,NDC,,,Outpatient,238,EA,37.77,,,,80,,30.22,percent of total billed charges,,,,85,32.1,percent of total billed charges,,,77.7,,29.35,percent of total billed charges,,,95,,35.88,percent of total billed charges,,,60,,22.66,percent of total billed charges,,22.66,35.88,
polyethylene glycol 3350 Oral Pwdr for Recon 238 gm [KHKS],6284571,CDM,250,RC,11523-7234-03,NDC,,,Inpatient,238,EA,37.77,,,,80,,30.22,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,29.35,percent of total billed charges,,,95,,35.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,35.88,
acetaminophen 160 mg/5 mL Susp UD 5 mL [KHKS],6284577,CDM,250,RC,00121-1781-05,NDC,,,Outpatient,5,ML,4.17,,,,80,,3.34,percent of total billed charges,,,,85,3.54,percent of total billed charges,,,77.7,,3.24,percent of total billed charges,,,95,,3.96,percent of total billed charges,,,60,,2.5,percent of total billed charges,,2.5,3.96,
acetaminophen 160 mg/5 mL Susp UD 5 mL [KHKS],6284577,CDM,250,RC,00121-1781-05,NDC,,,Inpatient,5,ML,4.17,,,,80,,3.34,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.24,percent of total billed charges,,,95,,3.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.96,
Al hydroxide/Mg hydroxide/simethicone 200 mg-200 mg-20 mg/5 mL Oral Susp UD 30 mL [KHKS],6284582,CDM,250,RC,66689-0060-99,NDC,,,Outpatient,30,ML,11.85,,,,80,,9.48,percent of total billed charges,,,,85,10.07,percent of total billed charges,,,77.7,,9.21,percent of total billed charges,,,95,,11.26,percent of total billed charges,,,60,,7.11,percent of total billed charges,,7.11,11.26,
Al hydroxide/Mg hydroxide/simethicone 200 mg-200 mg-20 mg/5 mL Oral Susp UD 30 mL [KHKS],6284582,CDM,250,RC,66689-0060-99,NDC,,,Inpatient,30,ML,11.85,,,,80,,9.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.21,percent of total billed charges,,,95,,11.26,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.26,
lidocaine 1% 10 mg/mL Sol 20 mL Vial MDV [KHKS],6284584,CDM,636,RC,J2003,HCPCS,63323-0485-27,NDC,Outpatient,20,ML,12.2,,,,80,,9.76,percent of total billed charges,,,,85,10.37,percent of total billed charges,,,77.7,,9.48,percent of total billed charges,,,95,,11.59,percent of total billed charges,,,60,,7.32,percent of total billed charges,,7.32,11.59,
lidocaine 1% 10 mg/mL Sol 20 mL Vial MDV [KHKS],6284584,CDM,636,RC,J2003,HCPCS,63323-0485-27,NDC,Inpatient,20,ML,12.2,,,,80,,9.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.48,percent of total billed charges,,,95,,11.59,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.59,
dextromethorphan ER 30 mg/5 mL Susp 89 mL [KHKS],6284586,CDM,250,RC,45802-0433-21,NDC,,,Outpatient,89,ML,22.95,,,,80,,18.36,percent of total billed charges,,,,85,19.51,percent of total billed charges,,,77.7,,17.83,percent of total billed charges,,,95,,21.8,percent of total billed charges,,,60,,13.77,percent of total billed charges,,13.77,21.8,
dextromethorphan ER 30 mg/5 mL Susp 89 mL [KHKS],6284586,CDM,250,RC,45802-0433-21,NDC,,,Inpatient,89,ML,22.95,,,,80,,18.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,17.83,percent of total billed charges,,,95,,21.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,21.8,
oseltamivir 30 mg Cap [KHKS],6284695,CDM,250,RC,00004-0802-85,NDC,,,Outpatient,1,EA,50.16,,,,80,,40.13,percent of total billed charges,,,,85,42.64,percent of total billed charges,,,77.7,,38.98,percent of total billed charges,,,95,,47.65,percent of total billed charges,,,60,,30.1,percent of total billed charges,,30.1,47.65,
oseltamivir 30 mg Cap [KHKS],6284695,CDM,250,RC,00004-0802-85,NDC,,,Inpatient,1,EA,50.16,,,,80,,40.13,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,38.98,percent of total billed charges,,,95,,47.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,47.65,
hydrocortisone topical 1% Cream 30 gm [KHKS],6284698,CDM,250,RC,49348-0441-72,NDC,,,Outpatient,30,EA,11.49,,,,80,,9.19,percent of total billed charges,,,,85,9.77,percent of total billed charges,,,77.7,,8.93,percent of total billed charges,,,95,,10.92,percent of total billed charges,,,60,,6.89,percent of total billed charges,,6.89,10.92,
hydrocortisone topical 1% Cream 30 gm [KHKS],6284698,CDM,250,RC,49348-0441-72,NDC,,,Inpatient,30,EA,11.49,,,,80,,9.19,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.93,percent of total billed charges,,,95,,10.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.92,
lidocaine 1% 10 mg/mL Inj Sol 2 mL [KHKS],6284719,CDM,636,RC,J2003,HCPCS,63323-0201-02,NDC,Outpatient,2,ML,7.2,,,,80,,5.76,percent of total billed charges,,,,85,6.12,percent of total billed charges,,,77.7,,5.59,percent of total billed charges,,,95,,6.84,percent of total billed charges,,,60,,4.32,percent of total billed charges,,4.32,6.84,
lidocaine 1% 10 mg/mL Inj Sol 2 mL [KHKS],6284719,CDM,636,RC,J2003,HCPCS,63323-0201-02,NDC,Inpatient,2,ML,7.2,,,,80,,5.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.59,percent of total billed charges,,,95,,6.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.84,
hydrALAZINE 20 mg/mL IV Sol 1 mL [KHKS],6284722,CDM,636,RC,J0360,HCPCS,63323-0614-55,NDC,Outpatient,1,ML,43.2,,,,80,,34.56,percent of total billed charges,,,,50,4.29,fee schedule,,,77.7,,33.57,percent of total billed charges,,,95,,41.04,percent of total billed charges,,,60,,25.92,percent of total billed charges,,4.29,41.04,
hydrALAZINE 20 mg/mL IV Sol 1 mL [KHKS],6284722,CDM,636,RC,J0360,HCPCS,63323-0614-55,NDC,Inpatient,1,ML,43.2,,,,80,,34.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,33.57,percent of total billed charges,,,95,,41.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,41.04,
losartan 100 mg Tab [KHKS],6284724,CDM,250,RC,43547-0362-09,NDC,,,Outpatient,1,EA,9.3,,,,80,,7.44,percent of total billed charges,,,,85,7.91,percent of total billed charges,,,77.7,,7.23,percent of total billed charges,,,95,,8.84,percent of total billed charges,,,60,,5.58,percent of total billed charges,,5.58,8.84,
losartan 100 mg Tab [KHKS],6284724,CDM,250,RC,43547-0362-09,NDC,,,Inpatient,1,EA,9.3,,,,80,,7.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.23,percent of total billed charges,,,95,,8.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,8.84,
alteplase 2 mg IV Inj [KHKS],6284899,CDM,636,RC,J2997,HCPCS,50242-0041-64,NDC,Outpatient,1,EA,372.85,,,,80,,298.28,percent of total billed charges,,,,50,56.44,fee schedule,,,77.7,,289.7,percent of total billed charges,,,95,,354.21,percent of total billed charges,,,60,,223.71,percent of total billed charges,,56.44,354.21,
alteplase 2 mg IV Inj [KHKS],6284899,CDM,636,RC,J2997,HCPCS,50242-0041-64,NDC,Inpatient,1,EA,372.85,,,,80,,298.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,289.7,percent of total billed charges,,,95,,354.21,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,354.21,
Sodium Chloride 0.9% IV Sol ADV-Bag 250 mL [KHKS],6284902,CDM,636,RC,J7050,HCPCS,00409-7101-02,NDC,Outpatient,250,ML,15.85,,,,80,,12.68,percent of total billed charges,,,,50,0.51,fee schedule,,,77.7,,12.31,percent of total billed charges,,,95,,15.06,percent of total billed charges,,,60,,9.51,percent of total billed charges,,0.51,15.06,
Sodium Chloride 0.9% IV Sol ADV-Bag 250 mL [KHKS],6284902,CDM,636,RC,J7050,HCPCS,00409-7101-02,NDC,Inpatient,250,ML,15.85,,,,80,,12.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.31,percent of total billed charges,,,95,,15.06,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.06,
morphine 10 mg/mL PF IV Sol 1 mL [KHKS],6284921,CDM,636,RC,J2270,HCPCS,00409-1893-01,NDC,Outpatient,1,ML,7.56,,,,80,,6.05,percent of total billed charges,,,,50,2.15,fee schedule,,,77.7,,5.87,percent of total billed charges,,,95,,7.18,percent of total billed charges,,,60,,4.53,percent of total billed charges,,2.15,7.18,
morphine 10 mg/mL PF IV Sol 1 mL [KHKS],6284921,CDM,636,RC,J2270,HCPCS,00409-1893-01,NDC,Inpatient,1,ML,7.56,,,,80,,6.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.87,percent of total billed charges,,,95,,7.18,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.18,
midazolam 2 mg/mL Syrup 118 mL [KHKS],6284922,CDM,250,RC,00054-3566-99,NDC,,,Outpatient,5,ML,32.33,,,,80,,25.86,percent of total billed charges,,,,85,27.48,percent of total billed charges,,,77.7,,25.12,percent of total billed charges,,,95,,30.71,percent of total billed charges,,,60,,19.4,percent of total billed charges,,19.4,30.71,
midazolam 2 mg/mL Syrup 118 mL [KHKS],6284922,CDM,250,RC,00054-3566-99,NDC,,,Inpatient,5,ML,32.33,,,,80,,25.86,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,25.12,percent of total billed charges,,,95,,30.71,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,30.71,
Sodium Chloride 0.9% IV Sol ADV-Bag 100 mL [KHKS],6285012,CDM,250,RC,00409-7101-67,NDC,,,Outpatient,100,ML,12.02,,,,80,,9.62,percent of total billed charges,,,,85,10.22,percent of total billed charges,,,77.7,,9.34,percent of total billed charges,,,95,,11.42,percent of total billed charges,,,60,,7.21,percent of total billed charges,,7.21,11.42,
Sodium Chloride 0.9% IV Sol ADV-Bag 100 mL [KHKS],6285012,CDM,250,RC,00409-7101-67,NDC,,,Inpatient,100,ML,12.02,,,,80,,9.62,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.34,percent of total billed charges,,,95,,11.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.42,
rifAMPin 300 mg Cap [KHKS],6312058,CDM,250,RC,68180-0659-06,NDC,,,Outpatient,1,EA,13.78,,,,80,,11.02,percent of total billed charges,,,,85,11.71,percent of total billed charges,,,77.7,,10.7,percent of total billed charges,,,95,,13.09,percent of total billed charges,,,60,,8.27,percent of total billed charges,,8.27,13.09,
rifAMPin 300 mg Cap [KHKS],6312058,CDM,250,RC,68180-0659-06,NDC,,,Inpatient,1,EA,13.78,,,,80,,11.02,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.7,percent of total billed charges,,,95,,13.09,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.09,
misoprostol 25mcg of a 100 mcg Tab [KHKS],6315682,CDM,250,RC,43386-0160-06QQ,NDC,,,Outpatient,1,EA,2.94,,,,80,,2.35,percent of total billed charges,,,,85,2.5,percent of total billed charges,,,77.7,,2.28,percent of total billed charges,,,95,,2.79,percent of total billed charges,,,60,,1.76,percent of total billed charges,,1.76,2.79,
misoprostol 25mcg of a 100 mcg Tab [KHKS],6315682,CDM,250,RC,43386-0160-06QQ,NDC,,,Inpatient,1,EA,2.94,,,,80,,2.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.28,percent of total billed charges,,,95,,2.79,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.79,
desmopressin 0.01% 10 mcg/inh Nasal Sray 5 mL [KHKS],6316010,CDM,250,RC,24208-0342-05,NDC,,,Outpatient,5,EA,455.58,,,,80,,364.46,percent of total billed charges,,,,85,387.24,percent of total billed charges,,,77.7,,353.99,percent of total billed charges,,,95,,432.8,percent of total billed charges,,,60,,273.35,percent of total billed charges,,273.35,432.8,
desmopressin 0.01% 10 mcg/inh Nasal Sray 5 mL [KHKS],6316010,CDM,250,RC,24208-0342-05,NDC,,,Inpatient,5,EA,455.58,,,,80,,364.46,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,353.99,percent of total billed charges,,,95,,432.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,432.8,
lidocaine 2% 100 mg/5 mL IV Sol 5 mL Syringe [KHKS],6316019,CDM,636,RC,J2003,HCPCS,00409-4903-34,NDC,Outpatient,5,ML,16.96,,,,80,,13.56,percent of total billed charges,,,,85,14.42,percent of total billed charges,,,77.7,,13.17,percent of total billed charges,,,95,,16.11,percent of total billed charges,,,60,,10.17,percent of total billed charges,,10.17,16.11,
lidocaine 2% 100 mg/5 mL IV Sol 5 mL Syringe [KHKS],6316019,CDM,636,RC,J2003,HCPCS,00409-4903-34,NDC,Inpatient,5,ML,16.96,,,,80,,13.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,13.17,percent of total billed charges,,,95,,16.11,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,16.11,
"epinephrine-lidocaine 1:100,000-1% Sol 10 mL [KHKS]",6316043,CDM,636,RC,J2004,HCPCS,63323-0482-17,NDC,Outpatient,10,ML,12.49,,,,80,,9.99,percent of total billed charges,,,,85,10.62,percent of total billed charges,,,77.7,,9.71,percent of total billed charges,,,95,,11.87,percent of total billed charges,,,60,,7.5,percent of total billed charges,,7.5,11.87,
"epinephrine-lidocaine 1:100,000-1% Sol 10 mL [KHKS]",6316043,CDM,636,RC,J2004,HCPCS,63323-0482-17,NDC,Inpatient,10,ML,12.49,,,,80,,9.99,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.71,percent of total billed charges,,,95,,11.87,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.87,
sterile water Inj Sol 20 mL Vial [KHKS],6316044,CDM,250,RC,00409-4887-20,NDC,,,Outpatient,20,ML,4.79,,,,80,,3.83,percent of total billed charges,,,,85,4.07,percent of total billed charges,,,77.7,,3.72,percent of total billed charges,,,95,,4.55,percent of total billed charges,,,60,,2.87,percent of total billed charges,,2.87,4.55,
sterile water Inj Sol 20 mL Vial [KHKS],6316044,CDM,250,RC,00409-4887-20,NDC,,,Inpatient,20,ML,4.79,,,,80,,3.83,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.72,percent of total billed charges,,,95,,4.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.55,
dilTIAZem 5 mg/mL IV Sol 5 mL [KHKS],6316051,CDM,250,RC,00641-9217-10,NDC,,,Outpatient,5,ML,7.85,,,,80,,6.28,percent of total billed charges,,,,85,6.67,percent of total billed charges,,,77.7,,6.1,percent of total billed charges,,,95,,7.46,percent of total billed charges,,,60,,4.71,percent of total billed charges,,4.71,7.46,
dilTIAZem 5 mg/mL IV Sol 5 mL [KHKS],6316051,CDM,250,RC,00641-9217-10,NDC,,,Inpatient,5,ML,7.85,,,,80,,6.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.1,percent of total billed charges,,,95,,7.46,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.46,
Sodium Chloride 3% IV Sol 500 mL [KHKS],6316052,CDM,636,RC,J7131,HCPCS,00264-7805-10,NDC,Outpatient,500,ML,17.18,,,,80,,13.74,percent of total billed charges,,,,50,0.02,fee schedule,,,77.7,,13.34,percent of total billed charges,,,95,,16.32,percent of total billed charges,,,60,,10.31,percent of total billed charges,,0.02,16.32,
Sodium Chloride 3% IV Sol 500 mL [KHKS],6316052,CDM,636,RC,J7131,HCPCS,00264-7805-10,NDC,Inpatient,500,ML,17.18,,,,80,,13.74,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,13.34,percent of total billed charges,,,95,,16.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,16.32,
lidocaine Top 4% (MM) 40 mg/mL Sol 5 mL [KHKS],6316060,CDM,250,RC,70954-0518-10QQ,NDC,,,Outpatient,5,ML,19.39,,,,80,,15.51,percent of total billed charges,,,,85,16.48,percent of total billed charges,,,77.7,,15.07,percent of total billed charges,,,95,,18.42,percent of total billed charges,,,60,,11.64,percent of total billed charges,,11.64,18.42,
lidocaine Top 4% (MM) 40 mg/mL Sol 5 mL [KHKS],6316060,CDM,250,RC,70954-0518-10QQ,NDC,,,Inpatient,5,ML,19.39,,,,80,,15.51,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,15.07,percent of total billed charges,,,95,,18.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,18.42,
docusate sodium 100 mg Cap [KHKS],6316357,CDM,250,RC,60687-0129-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
docusate sodium 100 mg Cap [KHKS],6316357,CDM,250,RC,60687-0129-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
levothyroxine 50 mcg (0.05 mg) Tab [KHKS],6316358,CDM,250,RC,00074-4552-11,NDC,,,Outpatient,1,EA,5.4,,,,80,,4.32,percent of total billed charges,,,,85,4.59,percent of total billed charges,,,77.7,,4.2,percent of total billed charges,,,95,,5.13,percent of total billed charges,,,60,,3.24,percent of total billed charges,,3.24,5.13,
levothyroxine 50 mcg (0.05 mg) Tab [KHKS],6316358,CDM,250,RC,00074-4552-11,NDC,,,Inpatient,1,EA,5.4,,,,80,,4.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.2,percent of total billed charges,,,95,,5.13,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.13,
EPINEPHrine 0.1 mg/mL Inj Sol 10 mL [KHKS],6316663,CDM,636,RC,J0171,HCPCS,76329-3318-01,NDC,Outpatient,10,ML,45,,,,80,,36,percent of total billed charges,,,,50,0.47,fee schedule,,,77.7,,34.97,percent of total billed charges,,,95,,42.75,percent of total billed charges,,,60,,27,percent of total billed charges,,0.47,42.75,
EPINEPHrine 0.1 mg/mL Inj Sol 10 mL [KHKS],6316663,CDM,636,RC,J0171,HCPCS,76329-3318-01,NDC,Inpatient,10,ML,45,,,,80,,36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,34.97,percent of total billed charges,,,95,,42.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,42.75,
ibuprofen 800 mg Tab [KHKS],6316976,CDM,250,RC,60687-0468-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
ibuprofen 800 mg Tab [KHKS],6316976,CDM,250,RC,60687-0468-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
bupivacaine 0.5% PF Inj Sol 30 mL [KHKS],6317015,CDM,636,RC,J0665,HCPCS,63323-0466-37,NDC,Outpatient,30,ML,26.1,,,,80,,20.88,percent of total billed charges,,,,85,22.19,percent of total billed charges,,,77.7,,20.28,percent of total billed charges,,,95,,24.8,percent of total billed charges,,,60,,15.66,percent of total billed charges,,15.66,24.8,
bupivacaine 0.5% PF Inj Sol 30 mL [KHKS],6317015,CDM,636,RC,J0665,HCPCS,63323-0466-37,NDC,Inpatient,30,ML,26.1,,,,80,,20.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,20.28,percent of total billed charges,,,95,,24.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,24.8,
ipratropium 0.5 mg/2.5 mL (0.02%) INH Sol 2.5 mL [KHKS],6317259,CDM,250,RC,60687-0394-83,NDC,,,Outpatient,2.5,ML,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
ipratropium 0.5 mg/2.5 mL (0.02%) INH Sol 2.5 mL [KHKS],6317259,CDM,250,RC,60687-0394-83,NDC,,,Inpatient,2.5,ML,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
budesonide 0.25 mg/2 mL INH Susp [KHKS],6317263,CDM,250,RC,J7626,HCPCS,00487-9601-01,NDC,Outpatient,2,ML,28.46,,,,80,,22.77,percent of total billed charges,,,,50,0.8,fee schedule,,,77.7,,22.11,percent of total billed charges,,,95,,27.04,percent of total billed charges,,,60,,17.08,percent of total billed charges,,0.8,27.04,
budesonide 0.25 mg/2 mL INH Susp [KHKS],6317263,CDM,250,RC,J7626,HCPCS,00487-9601-01,NDC,Inpatient,2,ML,28.46,,,,80,,22.77,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,22.11,percent of total billed charges,,,95,,27.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,27.04,
"bupivacaine-epinephrine 0.25%-1:200,000 Inj Sol 50 mL MDV [KHKS]",6317264,CDM,250,RC,63323-0461-57,NDC,,,Outpatient,1,ML,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
"bupivacaine-epinephrine 0.25%-1:200,000 Inj Sol 50 mL MDV [KHKS]",6317264,CDM,250,RC,63323-0461-57,NDC,,,Inpatient,1,ML,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
misoprostol 10 Tabs of 100 mcg = 1000 mcg Tab [KHKS],6317265,CDM,250,RC,43386-0160-06QZ,NDC,,,Outpatient,1,EA,30,,,,80,,24,percent of total billed charges,,,,85,25.5,percent of total billed charges,,,77.7,,23.31,percent of total billed charges,,,95,,28.5,percent of total billed charges,,,60,,18,percent of total billed charges,,18,28.5,
misoprostol 10 Tabs of 100 mcg = 1000 mcg Tab [KHKS],6317265,CDM,250,RC,43386-0160-06QZ,NDC,,,Inpatient,1,EA,30,,,,80,,24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,23.31,percent of total billed charges,,,95,,28.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,28.5,
glucagon 1 mg Inj [KHKS],6317649,CDM,636,RC,J1610,HCPCS,00548-5850-00,NDC,Outpatient,1,EA,621.6,,,,80,,497.28,percent of total billed charges,,,,50,122.38,fee schedule,,,77.7,,482.98,percent of total billed charges,,,95,,590.52,percent of total billed charges,,,60,,372.96,percent of total billed charges,,122.38,590.52,
glucagon 1 mg Inj [KHKS],6317649,CDM,636,RC,J1610,HCPCS,00548-5850-00,NDC,Inpatient,1,EA,621.6,,,,80,,497.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,482.98,percent of total billed charges,,,95,,590.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,590.52,
acetaminophen-HYDROcodone 325 mg-5 mg Tab [KHKS],6317657,CDM,250,RC,00406-0123-62,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
acetaminophen-HYDROcodone 325 mg-5 mg Tab [KHKS],6317657,CDM,250,RC,00406-0123-62,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
metroNIDAZOLE 250 mg Tab [KHKS],6317658,CDM,250,RC,00904-7156-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
metroNIDAZOLE 250 mg Tab [KHKS],6317658,CDM,250,RC,00904-7156-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
dicyclomine 10 mg Cap [KHKS],6318040,CDM,250,RC,60687-0369-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
dicyclomine 10 mg Cap [KHKS],6318040,CDM,250,RC,60687-0369-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
furosemide 20 mg Tab [KHKS],6318045,CDM,250,RC,00904-7177-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
furosemide 20 mg Tab [KHKS],6318045,CDM,250,RC,00904-7177-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
ampicillin 1 g Inj [KHKS],6318105,CDM,636,RC,J0290,HCPCS,00781-9404-95,NDC,Outpatient,1,EA,25.92,,,,80,,20.74,percent of total billed charges,,,,50,0.65,fee schedule,,,77.7,,20.14,percent of total billed charges,,,95,,24.62,percent of total billed charges,,,60,,15.55,percent of total billed charges,,0.65,24.62,
ampicillin 1 g Inj [KHKS],6318105,CDM,636,RC,J0290,HCPCS,00781-9404-95,NDC,Inpatient,1,EA,25.92,,,,80,,20.74,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,20.14,percent of total billed charges,,,95,,24.62,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,24.62,
DULoxetine 30 mg Cap [KHKS],6318106,CDM,250,RC,00904-7044-61,NDC,,,Outpatient,1,EA,5.17,,,,80,,4.14,percent of total billed charges,,,,85,4.39,percent of total billed charges,,,77.7,,4.02,percent of total billed charges,,,95,,4.91,percent of total billed charges,,,60,,3.1,percent of total billed charges,,3.1,4.91,
DULoxetine 30 mg Cap [KHKS],6318106,CDM,250,RC,00904-7044-61,NDC,,,Inpatient,1,EA,5.17,,,,80,,4.14,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.02,percent of total billed charges,,,95,,4.91,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.91,
albuterol 2.5 mg/3 mL (0.083%) INH Sol 3 mL [KHKS],6318191,CDM,250,RC,00487-9501-01,NDC,,,Outpatient,3,ML,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
albuterol 2.5 mg/3 mL (0.083%) INH Sol 3 mL [KHKS],6318191,CDM,250,RC,00487-9501-01,NDC,,,Inpatient,3,ML,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
docusate sodium 100 mg Cap [KHKS],6318333,CDM,250,RC,00904-7183-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
docusate sodium 100 mg Cap [KHKS],6318333,CDM,250,RC,00904-7183-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
ketorolac 30 mg/mL Inj Sol 1 mL [KHKS],6318544,CDM,636,RC,J1885,HCPCS,63323-0162-12,NDC,Outpatient,1,ML,3.13,,,,80,,2.51,percent of total billed charges,,,,50,0.38,fee schedule,,,77.7,,2.43,percent of total billed charges,,,95,,2.98,percent of total billed charges,,,60,,1.88,percent of total billed charges,,0.38,2.98,
ketorolac 30 mg/mL Inj Sol 1 mL [KHKS],6318544,CDM,636,RC,J1885,HCPCS,63323-0162-12,NDC,Inpatient,1,ML,3.13,,,,80,,2.51,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.43,percent of total billed charges,,,95,,2.98,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.98,
acetaminophen 325 mg Tab [KHKS],6318549,CDM,250,RC,00904-6773-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
acetaminophen 325 mg Tab [KHKS],6318549,CDM,250,RC,00904-6773-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
SUMAtriptan 6 mg/0.5 mL SQ Sol 0.5 mL[KHKS],6318552,CDM,636,RC,J3030,HCPCS,55150-0173-01,NDC,Outpatient,0.5,ML,39.6,,,,80,,31.68,percent of total billed charges,,,,50,30.98,fee schedule,,,77.7,,30.77,percent of total billed charges,,,95,,37.62,percent of total billed charges,,,60,,23.76,percent of total billed charges,,23.76,37.62,
SUMAtriptan 6 mg/0.5 mL SQ Sol 0.5 mL[KHKS],6318552,CDM,636,RC,J3030,HCPCS,55150-0173-01,NDC,Inpatient,0.5,ML,39.6,,,,80,,31.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,30.77,percent of total billed charges,,,95,,37.62,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,37.62,
acetaminophen-hydrocodone 325 mg-7.5 mg/15 mL ORAL Sol [KHKS],6318774,CDM,250,RC,66689-0023-50,NDC,,,Outpatient,15,ML,15.97,,,,80,,12.78,percent of total billed charges,,,,85,13.57,percent of total billed charges,,,77.7,,12.41,percent of total billed charges,,,95,,15.17,percent of total billed charges,,,60,,9.58,percent of total billed charges,,9.58,15.17,
acetaminophen-hydrocodone 325 mg-7.5 mg/15 mL ORAL Sol [KHKS],6318774,CDM,250,RC,66689-0023-50,NDC,,,Inpatient,15,ML,15.97,,,,80,,12.78,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.41,percent of total billed charges,,,95,,15.17,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.17,
amoxicillin-clavulanate 875 mg-125 mg Tab [KHKS],6319163,CDM,250,RC,16714-0014-01,NDC,,,Outpatient,1,EA,15.15,,,,80,,12.12,percent of total billed charges,,,,85,12.88,percent of total billed charges,,,77.7,,11.78,percent of total billed charges,,,95,,14.4,percent of total billed charges,,,60,,9.09,percent of total billed charges,,9.09,14.4,
amoxicillin-clavulanate 875 mg-125 mg Tab [KHKS],6319163,CDM,250,RC,16714-0014-01,NDC,,,Inpatient,1,EA,15.15,,,,80,,12.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.78,percent of total billed charges,,,95,,14.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,14.4,
ibuprofen 800 mg Tab [KHKS],6319164,CDM,250,RC,65162-0466-10,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
ibuprofen 800 mg Tab [KHKS],6319164,CDM,250,RC,65162-0466-10,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
pregabalin 75 mg Oral Cap [KHKS],6319165,CDM,250,RC,00904-7000-61,NDC,,,Outpatient,1,EA,2.76,,,,80,,2.21,percent of total billed charges,,,,85,2.35,percent of total billed charges,,,77.7,,2.15,percent of total billed charges,,,95,,2.63,percent of total billed charges,,,60,,1.66,percent of total billed charges,,1.66,2.63,
pregabalin 75 mg Oral Cap [KHKS],6319165,CDM,250,RC,00904-7000-61,NDC,,,Inpatient,1,EA,2.76,,,,80,,2.21,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.15,percent of total billed charges,,,95,,2.63,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.63,
albuterol-ipratropium 3 mg-0.5 mg/3 mL Sol [KHKS],6319998,CDM,250,RC,00378-9671-30,NDC,,,Outpatient,3,ML,6.55,,,,80,,5.24,percent of total billed charges,,,,85,5.57,percent of total billed charges,,,77.7,,5.09,percent of total billed charges,,,95,,6.23,percent of total billed charges,,,60,,3.93,percent of total billed charges,,3.93,6.23,
albuterol-ipratropium 3 mg-0.5 mg/3 mL Sol [KHKS],6319998,CDM,250,RC,00378-9671-30,NDC,,,Inpatient,3,ML,6.55,,,,80,,5.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.09,percent of total billed charges,,,95,,6.23,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.23,
levETIRAcetam 500 mg Tab,6320353,CDM,250,RC,00904-7124-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
levETIRAcetam 500 mg Tab,6320353,CDM,250,RC,00904-7124-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
meloxicam 7.5 mg Tab [KHKS],6320354,CDM,250,RC,50268-0525-15,NDC,,,Outpatient,1,EA,9.29,,,,80,,7.43,percent of total billed charges,,,,85,7.9,percent of total billed charges,,,77.7,,7.22,percent of total billed charges,,,95,,8.83,percent of total billed charges,,,60,,5.58,percent of total billed charges,,5.58,8.83,
meloxicam 7.5 mg Tab [KHKS],6320354,CDM,250,RC,50268-0525-15,NDC,,,Inpatient,1,EA,9.29,,,,80,,7.43,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.22,percent of total billed charges,,,95,,8.83,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,8.83,
colchicine 0.6 mg Tab [KHKS],6320355,CDM,250,RC,50268-0187-15,NDC,,,Outpatient,1,EA,21.59,,,,80,,17.28,percent of total billed charges,,,,85,18.35,percent of total billed charges,,,77.7,,16.78,percent of total billed charges,,,95,,20.51,percent of total billed charges,,,60,,12.96,percent of total billed charges,,12.96,20.51,
colchicine 0.6 mg Tab [KHKS],6320355,CDM,250,RC,50268-0187-15,NDC,,,Inpatient,1,EA,21.59,,,,80,,17.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,16.78,percent of total billed charges,,,95,,20.51,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,20.51,
"Penicillin G Potassium 5,000,000 units Pow-Inj [KHKS]",6320720,CDM,636,RC,J2540,HCPCS,00049-0520-83,NDC,Outpatient,1,EA,45.8,,,,80,,36.64,percent of total billed charges,,,,50,0.59,fee schedule,,,77.7,,35.58,percent of total billed charges,,,95,,43.51,percent of total billed charges,,,60,,27.48,percent of total billed charges,,0.59,43.51,
"Penicillin G Potassium 5,000,000 units Pow-Inj [KHKS]",6320720,CDM,636,RC,J2540,HCPCS,00049-0520-83,NDC,Inpatient,1,EA,45.8,,,,80,,36.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,35.58,percent of total billed charges,,,95,,43.51,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,43.51,
naloxone 0.4 mg/mL Inj Sol 1 mL [KHKS],6320899,CDM,636,RC,J2310,HCPCS,67457-0292-02,NDC,Outpatient,1,ML,71.17,,,,80,,56.94,percent of total billed charges,,,,50,6.62,fee schedule,,,77.7,,55.3,percent of total billed charges,,,95,,67.61,percent of total billed charges,,,60,,42.7,percent of total billed charges,,6.62,67.61,
naloxone 0.4 mg/mL Inj Sol 1 mL [KHKS],6320899,CDM,636,RC,J2310,HCPCS,67457-0292-02,NDC,Inpatient,1,ML,71.17,,,,80,,56.94,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,55.3,percent of total billed charges,,,95,,67.61,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,67.61,
ibuprofen 100 mg/5 mL Oral Susp 120 mL [KHKS],6320999,CDM,250,RC,51672-2130-08,NDC,,,Outpatient,120,ML,11.04,,,,80,,8.83,percent of total billed charges,,,,85,9.38,percent of total billed charges,,,77.7,,8.58,percent of total billed charges,,,95,,10.49,percent of total billed charges,,,60,,6.62,percent of total billed charges,,6.62,10.49,
ibuprofen 100 mg/5 mL Oral Susp 120 mL [KHKS],6320999,CDM,250,RC,51672-2130-08,NDC,,,Inpatient,120,ML,11.04,,,,80,,8.83,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.58,percent of total billed charges,,,95,,10.49,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.49,
RHo (D) immune globulin (1500 intl units) 300 mcg IM Sol [KHKS],6321201,CDM,636,RC,J2790,HCPCS,13533-0631-02,NDC,Outpatient,1,EA,248.11,,,,80,,198.49,percent of total billed charges,,,,50,51.69,fee schedule,,,77.7,,192.78,percent of total billed charges,,,95,,235.7,percent of total billed charges,,,60,,148.86,percent of total billed charges,,51.69,235.7,
RHo (D) immune globulin (1500 intl units) 300 mcg IM Sol [KHKS],6321201,CDM,636,RC,J2790,HCPCS,13533-0631-02,NDC,Inpatient,1,EA,248.11,,,,80,,198.49,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,192.78,percent of total billed charges,,,95,,235.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,235.7,
"Penicillin G Potassium 5,000,000 units Pow-Inj [KHKS]",6321753,CDM,636,RC,J2540,HCPCS,00049-0520-22,NDC,Outpatient,1,EA,45.8,,,,80,,36.64,percent of total billed charges,,,,50,0.59,fee schedule,,,77.7,,35.58,percent of total billed charges,,,95,,43.51,percent of total billed charges,,,60,,27.48,percent of total billed charges,,0.59,43.51,
"Penicillin G Potassium 5,000,000 units Pow-Inj [KHKS]",6321753,CDM,636,RC,J2540,HCPCS,00049-0520-22,NDC,Inpatient,1,EA,45.8,,,,80,,36.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,35.58,percent of total billed charges,,,95,,43.51,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,43.51,
cefdinir 300 mg Cap [KHKS],6321760,CDM,250,RC,68001-0362-06,NDC,,,Outpatient,1,EA,15.34,,,,80,,12.27,percent of total billed charges,,,,85,13.04,percent of total billed charges,,,77.7,,11.92,percent of total billed charges,,,95,,14.57,percent of total billed charges,,,60,,9.2,percent of total billed charges,,9.2,14.57,
cefdinir 300 mg Cap [KHKS],6321760,CDM,250,RC,68001-0362-06,NDC,,,Inpatient,1,EA,15.34,,,,80,,12.27,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.92,percent of total billed charges,,,95,,14.57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,14.57,
lidocaine Top 2% 20 mg/mL (MM) Sol 100 mL [KHKS],6322601,CDM,250,RC,62135-0712-42,NDC,,,Outpatient,1,ML,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
lidocaine Top 2% 20 mg/mL (MM) Sol 100 mL [KHKS],6322601,CDM,250,RC,62135-0712-42,NDC,,,Inpatient,1,ML,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
labetalol 5 mg/mL IV Sol 20 mL [KHKS],6323182,CDM,636,RC,J1920,HCPCS,00409-2267-20,NDC,Outpatient,1,ML,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
labetalol 5 mg/mL IV Sol 20 mL [KHKS],6323182,CDM,636,RC,J1920,HCPCS,00409-2267-20,NDC,Inpatient,1,ML,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
labetalol 5 mg/mL IV Sol 20 mL [KHKS],6323183,CDM,636,RC,J1920,HCPCS,72611-0734-01,NDC,Outpatient,1,ML,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
labetalol 5 mg/mL IV Sol 20 mL [KHKS],6323183,CDM,636,RC,J1920,HCPCS,72611-0734-01,NDC,Inpatient,1,ML,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
dexamethasone 4 mg/mL Inj Sol 1 mL [KHKS],6323464,CDM,636,RC,J1100,HCPCS,63323-0165-01,NDC,Outpatient,1,ML,10.37,,,,80,,8.29,percent of total billed charges,,,,50,0.08,fee schedule,,,77.7,,8.06,percent of total billed charges,,,95,,9.85,percent of total billed charges,,,60,,6.22,percent of total billed charges,,0.08,9.85,
dexamethasone 4 mg/mL Inj Sol 1 mL [KHKS],6323464,CDM,636,RC,J1100,HCPCS,63323-0165-01,NDC,Inpatient,1,ML,10.37,,,,80,,8.29,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.06,percent of total billed charges,,,95,,9.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.85,
sacubitril-valsartan 24 mg-26 mg Tab [KHKS],6324174,CDM,250,RC,00078-0659-20,NDC,,,Outpatient,1,EA,40.08,,,,80,,32.06,percent of total billed charges,,,,85,34.07,percent of total billed charges,,,77.7,,31.14,percent of total billed charges,,,95,,38.07,percent of total billed charges,,,60,,24.05,percent of total billed charges,,24.05,38.07,
sacubitril-valsartan 24 mg-26 mg Tab [KHKS],6324174,CDM,250,RC,00078-0659-20,NDC,,,Inpatient,1,EA,40.08,,,,80,,32.06,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,31.14,percent of total billed charges,,,95,,38.07,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,38.07,
ampicillin 2 g Inj [KHKS],6324603,CDM,636,RC,J0290,HCPCS,65219-0020-23,NDC,Outpatient,1,EA,28.58,,,,80,,22.87,percent of total billed charges,,,,50,0.65,fee schedule,,,77.7,,22.21,percent of total billed charges,,,95,,27.15,percent of total billed charges,,,60,,17.15,percent of total billed charges,,0.65,27.15,
ampicillin 2 g Inj [KHKS],6324603,CDM,636,RC,J0290,HCPCS,65219-0020-23,NDC,Inpatient,1,EA,28.58,,,,80,,22.87,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,22.21,percent of total billed charges,,,95,,27.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,27.15,
ibuprofen 100 mg/5 mL Oral Susp 120 mL [KHKS],6326695,CDM,250,RC,00904-5577-20,NDC,,,Outpatient,120,ML,14.83,,,,80,,11.86,percent of total billed charges,,,,85,12.61,percent of total billed charges,,,77.7,,11.52,percent of total billed charges,,,95,,14.09,percent of total billed charges,,,60,,8.9,percent of total billed charges,,8.9,14.09,
ibuprofen 100 mg/5 mL Oral Susp 120 mL [KHKS],6326695,CDM,250,RC,00904-5577-20,NDC,,,Inpatient,120,ML,14.83,,,,80,,11.86,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.52,percent of total billed charges,,,95,,14.09,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,14.09,
cefTRIAXone 500 mg Inj vial [KHKS],6326753,CDM,636,RC,J0696,HCPCS,00409-7338-01,NDC,Outpatient,1,EA,3.47,,,,80,,2.78,percent of total billed charges,,,,50,0.4,fee schedule,,,77.7,,2.7,percent of total billed charges,,,95,,3.3,percent of total billed charges,,,60,,2.08,percent of total billed charges,,0.4,3.3,
cefTRIAXone 500 mg Inj vial [KHKS],6326753,CDM,636,RC,J0696,HCPCS,00409-7338-01,NDC,Inpatient,1,EA,3.47,,,,80,,2.78,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.7,percent of total billed charges,,,95,,3.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.3,
aspirin 81 mg Oral EC Tab [KHKS],6327202,CDM,250,RC,70677-0163-2,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
aspirin 81 mg Oral EC Tab [KHKS],6327202,CDM,250,RC,70677-0163-2,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
magnesium sulfate 20 g/500mL-sterile water PREMIX IV Sol [KHKS],6328455,CDM,636,RC,J3475,HCPCS,63323-0106-15,NDC,Outpatient,500,ML,22.17,,,,80,,17.74,percent of total billed charges,,,,50,0.51,fee schedule,,,77.7,,17.23,percent of total billed charges,,,95,,21.06,percent of total billed charges,,,60,,13.3,percent of total billed charges,,0.51,21.06,
magnesium sulfate 20 g/500mL-sterile water PREMIX IV Sol [KHKS],6328455,CDM,636,RC,J3475,HCPCS,63323-0106-15,NDC,Inpatient,500,ML,22.17,,,,80,,17.74,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,17.23,percent of total billed charges,,,95,,21.06,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,21.06,
ketorolac 30 mg/mL Inj Sol 1 mL [KHKS],6328819,CDM,636,RC,J1885,HCPCS,62332-0600-25,NDC,Outpatient,1,ML,6.84,,,,80,,5.47,percent of total billed charges,,,,50,0.38,fee schedule,,,77.7,,5.31,percent of total billed charges,,,95,,6.5,percent of total billed charges,,,60,,4.1,percent of total billed charges,,0.38,6.5,
ketorolac 30 mg/mL Inj Sol 1 mL [KHKS],6328819,CDM,636,RC,J1885,HCPCS,62332-0600-25,NDC,Inpatient,1,ML,6.84,,,,80,,5.47,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.31,percent of total billed charges,,,95,,6.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.5,
cyclobenzaprine 10 mg Tab,6329107,CDM,250,RC,50268-0191-15,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
cyclobenzaprine 10 mg Tab,6329107,CDM,250,RC,50268-0191-15,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
clindamycin 150 mg/mL IV Sol 4 mL [KHKS],6329130,CDM,636,RC,J0736,HCPCS,00009-0775-26,NDC,Outpatient,4,ML,10.6,,,,80,,8.48,percent of total billed charges,,,,85,9.01,percent of total billed charges,,,77.7,,8.23,percent of total billed charges,,,95,,10.07,percent of total billed charges,,,60,,6.36,percent of total billed charges,,6.36,10.07,
clindamycin 150 mg/mL IV Sol 4 mL [KHKS],6329130,CDM,636,RC,J0736,HCPCS,00009-0775-26,NDC,Inpatient,4,ML,10.6,,,,80,,8.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.23,percent of total billed charges,,,95,,10.07,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.07,
senna 8.6 mg Tab [KHKS],6329836,CDM,250,RC,00904-7252-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
senna 8.6 mg Tab [KHKS],6329836,CDM,250,RC,00904-7252-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
enoxaparin 40 mg/0.4 mL Sol Syringe [KHKS],6329839,CDM,636,RC,J1650,HCPCS,63323-0564-65,NDC,Outpatient,0.4,ML,14.4,,,,80,,11.52,percent of total billed charges,,,,50,0.52,fee schedule,,,77.7,,11.19,percent of total billed charges,,,95,,13.68,percent of total billed charges,,,60,,8.64,percent of total billed charges,,0.52,13.68,
enoxaparin 40 mg/0.4 mL Sol Syringe [KHKS],6329839,CDM,636,RC,J1650,HCPCS,63323-0564-65,NDC,Inpatient,0.4,ML,14.4,,,,80,,11.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.19,percent of total billed charges,,,95,,13.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.68,
insulin isophane-insulin regular human recombinant 70 units-30 units/mL Sus,6330027,CDM,636,RC,J1815,HCPCS,00002-8715-01,NDC,Outpatient,1,ML,53.53,,,,80,,42.83,percent of total billed charges,,,,50,0.58,fee schedule,,,77.7,,41.59,percent of total billed charges,,,95,,50.86,percent of total billed charges,,,60,,32.12,percent of total billed charges,,0.58,50.86,
insulin isophane-insulin regular human recombinant 70 units-30 units/mL Sus,6330027,CDM,636,RC,J1815,HCPCS,00002-8715-01,NDC,Inpatient,1,ML,53.53,,,,80,,42.83,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,41.59,percent of total billed charges,,,95,,50.86,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,50.86,
meropenem 1 g IV Inj Vial [KHKS],6330820,CDM,636,RC,J2185,HCPCS,00409-1391-22,NDC,Outpatient,1,EA,74.54,,,,80,,59.63,percent of total billed charges,,,,50,0.47,fee schedule,,,77.7,,57.92,percent of total billed charges,,,95,,70.81,percent of total billed charges,,,60,,44.72,percent of total billed charges,,0.47,70.81,
meropenem 1 g IV Inj Vial [KHKS],6330820,CDM,636,RC,J2185,HCPCS,00409-1391-22,NDC,Inpatient,1,EA,74.54,,,,80,,59.63,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,57.92,percent of total billed charges,,,95,,70.81,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,70.81,
meropenem 1 g IV Inj Vial [KHKS],6330926,CDM,636,RC,J2185,HCPCS,00781-3098-95,NDC,Outpatient,1,EA,109.28,,,,80,,87.42,percent of total billed charges,,,,50,0.47,fee schedule,,,77.7,,84.91,percent of total billed charges,,,95,,103.81,percent of total billed charges,,,60,,65.57,percent of total billed charges,,0.47,103.81,
meropenem 1 g IV Inj Vial [KHKS],6330926,CDM,636,RC,J2185,HCPCS,00781-3098-95,NDC,Inpatient,1,EA,109.28,,,,80,,87.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,84.91,percent of total billed charges,,,95,,103.81,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,103.81,
metFORMIN 500 mg Tab [KHKS],6331095,CDM,250,RC,65862-0008-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
metFORMIN 500 mg Tab [KHKS],6331095,CDM,250,RC,65862-0008-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
oxyCODONE 5 mg Tab [KHKS],6331174,CDM,250,RC,00406-0552-62,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
oxyCODONE 5 mg Tab [KHKS],6331174,CDM,250,RC,00406-0552-62,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
finasteride 5 mg Tab [KHKS],6331207,CDM,250,RC,60687-0428-65,NDC,,,Outpatient,1,EA,2.88,,,,80,,2.3,percent of total billed charges,,,,85,2.45,percent of total billed charges,,,77.7,,2.24,percent of total billed charges,,,95,,2.74,percent of total billed charges,,,60,,1.73,percent of total billed charges,,1.73,2.74,
finasteride 5 mg Tab [KHKS],6331207,CDM,250,RC,60687-0428-65,NDC,,,Inpatient,1,EA,2.88,,,,80,,2.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.24,percent of total billed charges,,,95,,2.74,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.74,
acetaminophen 10 mg/mL Sol 100 mL Vial [KHKS],6331337,CDM,636,RC,J0131,HCPCS,24201-0110-24,NDC,Outpatient,100,ML,29.7,,,,80,,23.76,percent of total billed charges,,,,50,0.06,fee schedule,,,77.7,,23.08,percent of total billed charges,,,95,,28.22,percent of total billed charges,,,60,,17.82,percent of total billed charges,,0.06,28.22,
acetaminophen 10 mg/mL Sol 100 mL Vial [KHKS],6331337,CDM,636,RC,J0131,HCPCS,24201-0110-24,NDC,Inpatient,100,ML,29.7,,,,80,,23.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,23.08,percent of total billed charges,,,95,,28.22,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,28.22,
thiamine 100 mg/mL Inj Sol 2 mL [KHKS],6333078,CDM,636,RC,J3411,HCPCS,72603-0139-25,NDC,Outpatient,2,ML,33.88,,,,80,,27.11,percent of total billed charges,,,,50,1.81,fee schedule,,,77.7,,26.33,percent of total billed charges,,,95,,32.19,percent of total billed charges,,,60,,20.33,percent of total billed charges,,1.81,32.19,
thiamine 100 mg/mL Inj Sol 2 mL [KHKS],6333078,CDM,636,RC,J3411,HCPCS,72603-0139-25,NDC,Inpatient,2,ML,33.88,,,,80,,27.11,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,26.33,percent of total billed charges,,,95,,32.19,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,32.19,
benzocaine Top 20% Spray 0.5 mL [KHKS],6333098,CDM,250,RC,00283-0610-26,NDC,,,Outpatient,1,EA,33.43,,,,80,,26.74,percent of total billed charges,,,,85,28.42,percent of total billed charges,,,77.7,,25.97,percent of total billed charges,,,95,,31.76,percent of total billed charges,,,60,,20.06,percent of total billed charges,,20.06,31.76,
benzocaine Top 20% Spray 0.5 mL [KHKS],6333098,CDM,250,RC,00283-0610-26,NDC,,,Inpatient,1,EA,33.43,,,,80,,26.74,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,25.97,percent of total billed charges,,,95,,31.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,31.76,
doxycycline hyclate 100 mg Tab [KHKS],6333099,CDM,250,RC,27808-0234-02,NDC,,,Outpatient,1,EA,18.44,,,,80,,14.75,percent of total billed charges,,,,85,15.67,percent of total billed charges,,,77.7,,14.33,percent of total billed charges,,,95,,17.52,percent of total billed charges,,,60,,11.06,percent of total billed charges,,11.06,17.52,
doxycycline hyclate 100 mg Tab [KHKS],6333099,CDM,250,RC,27808-0234-02,NDC,,,Inpatient,1,EA,18.44,,,,80,,14.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.33,percent of total billed charges,,,95,,17.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.52,
dalbavancin 500 mg Inj Vial [KHKS],6333280,CDM,636,RC,J0875,HCPCS,57970-0100-01,NDC,Outpatient,1,EA,3834.63,,,,80,,3067.7,percent of total billed charges,,,,50,9.86,fee schedule,,,77.7,,2979.51,percent of total billed charges,,,95,,3642.9,percent of total billed charges,,,60,,2300.78,percent of total billed charges,,9.86,3642.9,
dalbavancin 500 mg Inj Vial [KHKS],6333280,CDM,636,RC,J0875,HCPCS,57970-0100-01,NDC,Inpatient,1,EA,3834.63,,,,80,,3067.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2979.51,percent of total billed charges,,,95,,3642.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3642.9,
menthol-zinc oxide topical 0.44%-20.6% Oin,6334020,CDM,250,RC,00799-0001-02,NDC,,,Outpatient,71,EA,14.07,,,,80,,11.26,percent of total billed charges,,,,85,11.96,percent of total billed charges,,,77.7,,10.93,percent of total billed charges,,,95,,13.37,percent of total billed charges,,,60,,8.44,percent of total billed charges,,8.44,13.37,
menthol-zinc oxide topical 0.44%-20.6% Oin,6334020,CDM,250,RC,00799-0001-02,NDC,,,Inpatient,71,EA,14.07,,,,80,,11.26,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.93,percent of total billed charges,,,95,,13.37,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.37,
bupivacaine 0.25% PF Inj Sol 10 mL Vial [KHKS],6335233,CDM,636,RC,J0665,HCPCS,55150-0167-10,NDC,Outpatient,10,ML,9.36,,,,80,,7.49,percent of total billed charges,,,,85,7.96,percent of total billed charges,,,77.7,,7.27,percent of total billed charges,,,95,,8.89,percent of total billed charges,,,60,,5.62,percent of total billed charges,,5.62,8.89,
bupivacaine 0.25% PF Inj Sol 10 mL Vial [KHKS],6335233,CDM,636,RC,J0665,HCPCS,55150-0167-10,NDC,Inpatient,10,ML,9.36,,,,80,,7.49,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.27,percent of total billed charges,,,95,,8.89,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,8.89,
RHo (D) immune globulin 1500 intl units/1.3 mL Sol [KHKS],6335648,CDM,636,RC,J2792,HCPCS,70257-0330-51,NDC,Outpatient,1.3,ML,1142.43,,,,80,,913.94,percent of total billed charges,,,,50,21.17,fee schedule,,,77.7,,887.67,percent of total billed charges,,,95,,1085.31,percent of total billed charges,,,60,,685.46,percent of total billed charges,,21.17,1085.31,
RHo (D) immune globulin 1500 intl units/1.3 mL Sol [KHKS],6335648,CDM,636,RC,J2792,HCPCS,70257-0330-51,NDC,Inpatient,1.3,ML,1142.43,,,,80,,913.94,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,887.67,percent of total billed charges,,,95,,1085.31,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1085.31,
midodrine 5 mg Tab [KHKS],6336055,CDM,250,RC,00245-0212-89,NDC,,,Outpatient,1,EA,13.46,,,,80,,10.77,percent of total billed charges,,,,85,11.44,percent of total billed charges,,,77.7,,10.46,percent of total billed charges,,,95,,12.79,percent of total billed charges,,,60,,8.08,percent of total billed charges,,8.08,12.79,
midodrine 5 mg Tab [KHKS],6336055,CDM,250,RC,00245-0212-89,NDC,,,Inpatient,1,EA,13.46,,,,80,,10.77,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.46,percent of total billed charges,,,95,,12.79,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,12.79,
ondansetron 2 mg/mL Inj Sol 2 mL [KHKS],6338657,CDM,636,RC,J2405,HCPCS,00641-6080-25,NDC,Outpatient,2,ML,3.42,,,,80,,2.74,percent of total billed charges,,,,50,0.06,fee schedule,,,77.7,,2.66,percent of total billed charges,,,95,,3.25,percent of total billed charges,,,60,,2.05,percent of total billed charges,,0.06,3.25,
ondansetron 2 mg/mL Inj Sol 2 mL [KHKS],6338657,CDM,636,RC,J2405,HCPCS,00641-6080-25,NDC,Inpatient,2,ML,3.42,,,,80,,2.74,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.66,percent of total billed charges,,,95,,3.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.25,
carbidopa-levodopa 10 mg-100 mg Tab [KHKS],6338726,CDM,250,RC,42291-0465-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
carbidopa-levodopa 10 mg-100 mg Tab [KHKS],6338726,CDM,250,RC,42291-0465-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
dilTIAZem 5 mg/mL IV Sol 5 mL [KHKS],6338857,CDM,250,RC,00641-6013-10,NDC,,,Outpatient,5,ML,12.31,,,,80,,9.85,percent of total billed charges,,,,85,10.46,percent of total billed charges,,,77.7,,9.57,percent of total billed charges,,,95,,11.7,percent of total billed charges,,,60,,7.39,percent of total billed charges,,7.39,11.7,
dilTIAZem 5 mg/mL IV Sol 5 mL [KHKS],6338857,CDM,250,RC,00641-6013-10,NDC,,,Inpatient,5,ML,12.31,,,,80,,9.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.57,percent of total billed charges,,,95,,11.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.7,
carbidopa-levodopa 25 mg-100 mg Tab [KHKS],6339227,CDM,250,RC,00904-7257-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
carbidopa-levodopa 25 mg-100 mg Tab [KHKS],6339227,CDM,250,RC,00904-7257-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
bumetanide 1 mg Tab [KHKS],6339424,CDM,250,RC,60687-0384-25,NDC,,,Outpatient,1,EA,5.87,,,,80,,4.7,percent of total billed charges,,,,85,4.99,percent of total billed charges,,,77.7,,4.56,percent of total billed charges,,,95,,5.58,percent of total billed charges,,,60,,3.52,percent of total billed charges,,3.52,5.58,
bumetanide 1 mg Tab [KHKS],6339424,CDM,250,RC,60687-0384-25,NDC,,,Inpatient,1,EA,5.87,,,,80,,4.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.56,percent of total billed charges,,,95,,5.58,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.58,
benzonatate 100 mg Cap [KHKS],6340968,CDM,250,RC,00904-7153-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
benzonatate 100 mg Cap [KHKS],6340968,CDM,250,RC,00904-7153-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
betamethasone acetate-betamethasone sodium phosphate 3 mg-3 mg Inj Susp 5 mL [KHKS],6340970,CDM,636,RC,J0702,HCPCS,00517-0791-01,NDC,Outpatient,5,ML,185.4,,,,80,,148.32,percent of total billed charges,,,,50,4.38,fee schedule,,,77.7,,144.06,percent of total billed charges,,,95,,176.13,percent of total billed charges,,,60,,111.24,percent of total billed charges,,4.38,176.13,
betamethasone acetate-betamethasone sodium phosphate 3 mg-3 mg Inj Susp 5 mL [KHKS],6340970,CDM,636,RC,J0702,HCPCS,00517-0791-01,NDC,Inpatient,5,ML,185.4,,,,80,,148.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,144.06,percent of total billed charges,,,95,,176.13,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,176.13,
promethazine 50 mg/mL Inj Sol 1 mL [KHKS],6340971,CDM,636,RC,J2550,HCPCS,00641-1496-35,NDC,Outpatient,1,ML,9.32,,,,80,,7.46,percent of total billed charges,,,,50,2.07,fee schedule,,,77.7,,7.24,percent of total billed charges,,,95,,8.86,percent of total billed charges,,,60,,5.59,percent of total billed charges,,2.07,8.86,
promethazine 50 mg/mL Inj Sol 1 mL [KHKS],6340971,CDM,636,RC,J2550,HCPCS,00641-1496-35,NDC,Inpatient,1,ML,9.32,,,,80,,7.46,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.24,percent of total billed charges,,,95,,8.86,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,8.86,
ibuprofen 200 mg Tab [KHKS],6341824,CDM,250,RC,00904-7914-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
ibuprofen 200 mg Tab [KHKS],6341824,CDM,250,RC,00904-7914-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
piperacillin-tazobactam 3.375 g IV Inj Vial [KHKS],6341987,CDM,636,RC,J2543,HCPCS,00781-9213-95,NDC,Outpatient,1,EA,55.39,,,,80,,44.31,percent of total billed charges,,,,50,1.15,fee schedule,,,77.7,,43.04,percent of total billed charges,,,95,,52.62,percent of total billed charges,,,60,,33.24,percent of total billed charges,,1.15,52.62,
piperacillin-tazobactam 3.375 g IV Inj Vial [KHKS],6341987,CDM,636,RC,J2543,HCPCS,00781-9213-95,NDC,Inpatient,1,EA,55.39,,,,80,,44.31,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,43.04,percent of total billed charges,,,95,,52.62,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,52.62,
cefdinir 300 mg Cap [KHKS],6345178,CDM,250,RC,67877-0543-60,NDC,,,Outpatient,1,EA,15.32,,,,80,,12.25,percent of total billed charges,,,,85,13.02,percent of total billed charges,,,77.7,,11.9,percent of total billed charges,,,95,,14.55,percent of total billed charges,,,60,,9.19,percent of total billed charges,,9.19,14.55,
cefdinir 300 mg Cap [KHKS],6345178,CDM,250,RC,67877-0543-60,NDC,,,Inpatient,1,EA,15.32,,,,80,,12.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.9,percent of total billed charges,,,95,,14.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,14.55,
gentamicin 10 mg/mL Inj Sol 2 mL [KHKS],6345188,CDM,636,RC,J1580,HCPCS,63323-0173-02,NDC,Outpatient,2,ML,19.48,,,,80,,15.58,percent of total billed charges,,,,50,2.11,fee schedule,,,77.7,,15.13,percent of total billed charges,,,95,,18.5,percent of total billed charges,,,60,,11.69,percent of total billed charges,,2.11,18.5,
gentamicin 10 mg/mL Inj Sol 2 mL [KHKS],6345188,CDM,636,RC,J1580,HCPCS,63323-0173-02,NDC,Inpatient,2,ML,19.48,,,,80,,15.58,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,15.13,percent of total billed charges,,,95,,18.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,18.5,
"nystatin 100,000 units/mL Oral Susp 60 mL [KHKS]",6345534,CDM,250,RC,69315-0504-60,NDC,,,Outpatient,60,ML,43.2,,,,80,,34.56,percent of total billed charges,,,,85,36.72,percent of total billed charges,,,77.7,,33.57,percent of total billed charges,,,95,,41.04,percent of total billed charges,,,60,,25.92,percent of total billed charges,,25.92,41.04,
"nystatin 100,000 units/mL Oral Susp 60 mL [KHKS]",6345534,CDM,250,RC,69315-0504-60,NDC,,,Inpatient,60,ML,43.2,,,,80,,34.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,33.57,percent of total billed charges,,,95,,41.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,41.04,
piperacillin-tazobactam 4.5 g IV Inj Vial [KHKS],6346472,CDM,636,RC,J2543,HCPCS,00781-9214-95,NDC,Outpatient,1,EA,70.16,,,,80,,56.12,percent of total billed charges,,,,50,1.15,fee schedule,,,77.7,,54.51,percent of total billed charges,,,95,,66.65,percent of total billed charges,,,60,,42.09,percent of total billed charges,,1.15,66.65,
piperacillin-tazobactam 4.5 g IV Inj Vial [KHKS],6346472,CDM,636,RC,J2543,HCPCS,00781-9214-95,NDC,Inpatient,1,EA,70.16,,,,80,,56.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,54.51,percent of total billed charges,,,95,,66.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,66.65,
ipratropium 0.5 mg/2.5 mL (0.02%) INH Sol 2.5 mL [KHKS],6346473,CDM,250,RC,76204-0100-01,NDC,,,Outpatient,2.5,ML,5.54,,,,80,,4.44,percent of total billed charges,,,,85,4.71,percent of total billed charges,,,77.7,,4.31,percent of total billed charges,,,95,,5.27,percent of total billed charges,,,60,,3.33,percent of total billed charges,,3.33,5.27,
ipratropium 0.5 mg/2.5 mL (0.02%) INH Sol 2.5 mL [KHKS],6346473,CDM,250,RC,76204-0100-01,NDC,,,Inpatient,2.5,ML,5.54,,,,80,,4.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.31,percent of total billed charges,,,95,,5.27,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.27,
pantoprazole 40 mg Oral EC Tab [KHKS],6346474,CDM,250,RC,51079-0051-20,NDC,,,Outpatient,1,EA,15.8,,,,80,,12.64,percent of total billed charges,,,,85,13.43,percent of total billed charges,,,77.7,,12.28,percent of total billed charges,,,95,,15.01,percent of total billed charges,,,60,,9.48,percent of total billed charges,,9.48,15.01,
pantoprazole 40 mg Oral EC Tab [KHKS],6346474,CDM,250,RC,51079-0051-20,NDC,,,Inpatient,1,EA,15.8,,,,80,,12.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.28,percent of total billed charges,,,95,,15.01,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.01,
melatonin 3 mg Tab [KHKS],6346476,CDM,250,RC,50268-0524-15,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
melatonin 3 mg Tab [KHKS],6346476,CDM,250,RC,50268-0524-15,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
oxymetazoline Nasal 0.05% Spry 15 mL [KHKS],6347864,CDM,250,RC,11523-1167-06,NDC,,,Outpatient,15,EA,19.98,,,,80,,15.98,percent of total billed charges,,,,85,16.98,percent of total billed charges,,,77.7,,15.52,percent of total billed charges,,,95,,18.98,percent of total billed charges,,,60,,11.99,percent of total billed charges,,11.99,18.98,
oxymetazoline Nasal 0.05% Spry 15 mL [KHKS],6347864,CDM,250,RC,11523-1167-06,NDC,,,Inpatient,15,EA,19.98,,,,80,,15.98,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,15.52,percent of total billed charges,,,95,,18.98,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,18.98,
ceFAZolin 1 g Inj [KHKS],6351983,CDM,636,RC,J0690,HCPCS,00143-9924-90,NDC,Outpatient,1,EA,4.92,,,,80,,3.94,percent of total billed charges,,,,50,0.55,fee schedule,,,77.7,,3.83,percent of total billed charges,,,95,,4.68,percent of total billed charges,,,60,,2.95,percent of total billed charges,,0.55,4.68,
ceFAZolin 1 g Inj [KHKS],6351983,CDM,636,RC,J0690,HCPCS,00143-9924-90,NDC,Inpatient,1,EA,4.92,,,,80,,3.94,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.83,percent of total billed charges,,,95,,4.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.68,
albuterol-ipratropium 3 mg-0.5 mg/3 mL Sol [KHKS],6352123,CDM,250,RC,60687-0405-83,NDC,,,Outpatient,3,ML,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
albuterol-ipratropium 3 mg-0.5 mg/3 mL Sol [KHKS],6352123,CDM,250,RC,60687-0405-83,NDC,,,Inpatient,3,ML,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
tranexamic acid 100 mg/mL IV Sol 10 mL [KHKS],6352385,CDM,250,RC,43066-0008-10,NDC,,,Outpatient,10,ML,15.84,,,,80,,12.67,percent of total billed charges,,,,85,13.46,percent of total billed charges,,,77.7,,12.31,percent of total billed charges,,,95,,15.05,percent of total billed charges,,,60,,9.5,percent of total billed charges,,9.5,15.05,
tranexamic acid 100 mg/mL IV Sol 10 mL [KHKS],6352385,CDM,250,RC,43066-0008-10,NDC,,,Inpatient,10,ML,15.84,,,,80,,12.67,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.31,percent of total billed charges,,,95,,15.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.05,
levothyroxine 50 mcg (0.05 mg) Tab [KHKS],6352388,CDM,250,RC,60687-0464-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
levothyroxine 50 mcg (0.05 mg) Tab [KHKS],6352388,CDM,250,RC,60687-0464-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
DOBUTamine 12.5 mg/mL IV Sol 20 mL [KHKS],6352491,CDM,636,RC,J1250,HCPCS,70436-0203-82,NDC,Outpatient,20,ML,23.32,,,,80,,18.66,percent of total billed charges,,,,50,4.48,fee schedule,,,77.7,,18.12,percent of total billed charges,,,95,,22.16,percent of total billed charges,,,60,,13.99,percent of total billed charges,,4.48,22.16,
DOBUTamine 12.5 mg/mL IV Sol 20 mL [KHKS],6352491,CDM,636,RC,J1250,HCPCS,70436-0203-82,NDC,Inpatient,20,ML,23.32,,,,80,,18.66,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,18.12,percent of total billed charges,,,95,,22.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,22.16,
famotidine 40 mg/5 mL Pow 50 mL [KHKS],6352564,CDM,250,RC,70954-0316-10,NDC,,,Outpatient,50,ML,398.14,,,,80,,318.51,percent of total billed charges,,,,85,338.42,percent of total billed charges,,,77.7,,309.35,percent of total billed charges,,,95,,378.23,percent of total billed charges,,,60,,238.88,percent of total billed charges,,238.88,378.23,
famotidine 40 mg/5 mL Pow 50 mL [KHKS],6352564,CDM,250,RC,70954-0316-10,NDC,,,Inpatient,50,ML,398.14,,,,80,,318.51,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,309.35,percent of total billed charges,,,95,,378.23,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,378.23,
glycopyrrolate 0.2 mg/mL Inj Sol 5 mL MDV [KHKS],6352715,CDM,636,RC,J1596,HCPCS,71288-0415-06,NDC,Outpatient,5,ML,28.8,,,,80,,23.04,percent of total billed charges,,,,85,24.48,percent of total billed charges,,,77.7,,22.38,percent of total billed charges,,,95,,27.36,percent of total billed charges,,,60,,17.28,percent of total billed charges,,17.28,27.36,
glycopyrrolate 0.2 mg/mL Inj Sol 5 mL MDV [KHKS],6352715,CDM,636,RC,J1596,HCPCS,71288-0415-06,NDC,Inpatient,5,ML,28.8,,,,80,,23.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,22.38,percent of total billed charges,,,95,,27.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,27.36,
lidocaine Top 2% 20 mg/mL (MM) Sol 100 mL [KHKS],6352716,CDM,250,RC,72888-0125-26,NDC,,,Outpatient,1,ML,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
lidocaine Top 2% 20 mg/mL (MM) Sol 100 mL [KHKS],6352716,CDM,250,RC,72888-0125-26,NDC,,,Inpatient,1,ML,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
baclofen 10 mg Tab,6354449,CDM,250,RC,16714-0071-04,NDC,,,Outpatient,1,EA,7.41,,,,80,,5.93,percent of total billed charges,,,,85,6.3,percent of total billed charges,,,77.7,,5.76,percent of total billed charges,,,95,,7.04,percent of total billed charges,,,60,,4.45,percent of total billed charges,,4.45,7.04,
baclofen 10 mg Tab,6354449,CDM,250,RC,16714-0071-04,NDC,,,Inpatient,1,EA,7.41,,,,80,,5.93,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.76,percent of total billed charges,,,95,,7.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.04,
venlafaxine 75 mg Cap,6354450,CDM,250,RC,68084-0709-01,NDC,,,Outpatient,1,EA,12.59,,,,80,,10.07,percent of total billed charges,,,,85,10.7,percent of total billed charges,,,77.7,,9.78,percent of total billed charges,,,95,,11.96,percent of total billed charges,,,60,,7.55,percent of total billed charges,,7.55,11.96,
venlafaxine 75 mg Cap,6354450,CDM,250,RC,68084-0709-01,NDC,,,Inpatient,1,EA,12.59,,,,80,,10.07,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.78,percent of total billed charges,,,95,,11.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.96,
tetracaine OPHTH 0.5% Sol 15 mL [KHKS],6355091,CDM,250,RC,68682-0920-64,NDC,,,Outpatient,15,EA,243,,,,80,,194.4,percent of total billed charges,,,,85,206.55,percent of total billed charges,,,77.7,,188.81,percent of total billed charges,,,95,,230.85,percent of total billed charges,,,60,,145.8,percent of total billed charges,,145.8,230.85,
tetracaine OPHTH 0.5% Sol 15 mL [KHKS],6355091,CDM,250,RC,68682-0920-64,NDC,,,Inpatient,15,EA,243,,,,80,,194.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,188.81,percent of total billed charges,,,95,,230.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,230.85,
epinephrine-lidocaine 1:100000-2% Inj Sol 20 mL [KHKS],6355936,CDM,J2004,HCPCS,00409-3182-01,NDC,,,Outpatient,20,ML,12.02,,,,80,,9.61,percent of total billed charges,,,,85,10.22,percent of total billed charges,,,77.7,,9.34,percent of total billed charges,,,95,,11.42,percent of total billed charges,,,60,,7.21,percent of total billed charges,,7.21,11.42,
epinephrine-lidocaine 1:100000-2% Inj Sol 20 mL [KHKS],6355936,CDM,J2004,HCPCS,00409-3182-01,NDC,,,Inpatient,20,ML,12.02,,,,80,,9.61,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.34,percent of total billed charges,,,95,,11.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.42,
DAPTOmycin 500 mg IV Inj Sol [KHKS],6357290,CDM,636,RC,J0878,HCPCS,71288-0016-95,NDC,Outpatient,1,EA,283.5,,,,80,,226.8,percent of total billed charges,,,,50,0.13,fee schedule,,,77.7,,220.28,percent of total billed charges,,,95,,269.33,percent of total billed charges,,,60,,170.1,percent of total billed charges,,0.13,269.33,
DAPTOmycin 500 mg IV Inj Sol [KHKS],6357290,CDM,636,RC,J0878,HCPCS,71288-0016-95,NDC,Inpatient,1,EA,283.5,,,,80,,226.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,220.28,percent of total billed charges,,,95,,269.33,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,269.33,
heparin 5000 units/mL Inj Sol 1 mL [KHKS],6359003,CDM,636,RC,J1644,HCPCS,25021-0402-01,NDC,Outpatient,1,ML,5.4,,,,80,,4.32,percent of total billed charges,,,,50,0.17,fee schedule,,,77.7,,4.2,percent of total billed charges,,,95,,5.13,percent of total billed charges,,,60,,3.24,percent of total billed charges,,0.17,5.13,
heparin 5000 units/mL Inj Sol 1 mL [KHKS],6359003,CDM,636,RC,J1644,HCPCS,25021-0402-01,NDC,Inpatient,1,ML,5.4,,,,80,,4.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.2,percent of total billed charges,,,95,,5.13,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.13,
dexamethasone 10 mg/mL PF Inj Sol 1 mL [KHKS],6360321,CDM,636,RC,J1100,HCPCS,55150-0304-25,NDC,Outpatient,1,ML,15.84,,,,80,,12.67,percent of total billed charges,,,,50,0.08,fee schedule,,,77.7,,12.31,percent of total billed charges,,,95,,15.05,percent of total billed charges,,,60,,9.5,percent of total billed charges,,0.08,15.05,
dexamethasone 10 mg/mL PF Inj Sol 1 mL [KHKS],6360321,CDM,636,RC,J1100,HCPCS,55150-0304-25,NDC,Inpatient,1,ML,15.84,,,,80,,12.67,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.31,percent of total billed charges,,,95,,15.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.05,
erythromycin ophthalmic 0.5% Oint 3.5 gm [KHKS],6360572,CDM,250,RC,24208-0910-55,NDC,,,Outpatient,3.5,EA,57,,,,80,,45.6,percent of total billed charges,,,,85,48.45,percent of total billed charges,,,77.7,,44.29,percent of total billed charges,,,95,,54.15,percent of total billed charges,,,60,,34.2,percent of total billed charges,,34.2,54.15,
erythromycin ophthalmic 0.5% Oint 3.5 gm [KHKS],6360572,CDM,250,RC,24208-0910-55,NDC,,,Inpatient,3.5,EA,57,,,,80,,45.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,44.29,percent of total billed charges,,,95,,54.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,54.15,
bumetanide 1 mg Tab [KHKS],6360573,CDM,250,RC,50268-0131-15,NDC,,,Outpatient,1,EA,4.5,,,,80,,3.6,percent of total billed charges,,,,85,3.83,percent of total billed charges,,,77.7,,3.5,percent of total billed charges,,,95,,4.27,percent of total billed charges,,,60,,2.7,percent of total billed charges,,2.7,4.27,
bumetanide 1 mg Tab [KHKS],6360573,CDM,250,RC,50268-0131-15,NDC,,,Inpatient,1,EA,4.5,,,,80,,3.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.5,percent of total billed charges,,,95,,4.27,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.27,
cyclobenzaprine 10 mg Tab,6360574,CDM,250,RC,60687-0558-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
cyclobenzaprine 10 mg Tab,6360574,CDM,250,RC,60687-0558-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
pantoprazole 40 mg Oral EC Tab [KHKS],6360576,CDM,250,RC,35573-0428-80,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
pantoprazole 40 mg Oral EC Tab [KHKS],6360576,CDM,250,RC,35573-0428-80,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
allopurinol 100 mg Tab [KHKS],6360617,CDM,250,RC,51079-0205-20,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
allopurinol 100 mg Tab [KHKS],6360617,CDM,250,RC,51079-0205-20,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
ramelteon 8 mg Tab [KHKS],6360643,CDM,250,RC,52817-0235-30,NDC,,,Outpatient,1,EA,41.97,,,,80,,33.58,percent of total billed charges,,,,85,35.67,percent of total billed charges,,,77.7,,32.61,percent of total billed charges,,,95,,39.87,percent of total billed charges,,,60,,25.18,percent of total billed charges,,25.18,39.87,
ramelteon 8 mg Tab [KHKS],6360643,CDM,250,RC,52817-0235-30,NDC,,,Inpatient,1,EA,41.97,,,,80,,33.58,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,32.61,percent of total billed charges,,,95,,39.87,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,39.87,
potassium chloride 20 mEq/15 mL Oral Liq 15 mL [KHKS],6361494,CDM,250,RC,43598-0891-52,NDC,,,Outpatient,15,ML,22.68,,,,80,,18.14,percent of total billed charges,,,,85,19.28,percent of total billed charges,,,77.7,,17.62,percent of total billed charges,,,95,,21.55,percent of total billed charges,,,60,,13.61,percent of total billed charges,,13.61,21.55,
potassium chloride 20 mEq/15 mL Oral Liq 15 mL [KHKS],6361494,CDM,250,RC,43598-0891-52,NDC,,,Inpatient,15,ML,22.68,,,,80,,18.14,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,17.62,percent of total billed charges,,,95,,21.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,21.55,
losartan 50 mg Tab [KHKS],6361757,CDM,250,RC,00904-7048-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
losartan 50 mg Tab [KHKS],6361757,CDM,250,RC,00904-7048-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
heparin 5000 units/mL Inj Sol 1 mL [KHKS],6361771,CDM,636,RC,J1644,HCPCS,63323-0262-06,NDC,Outpatient,1,ML,14.98,,,,80,,11.98,percent of total billed charges,,,,50,0.17,fee schedule,,,77.7,,11.64,percent of total billed charges,,,95,,14.23,percent of total billed charges,,,60,,8.99,percent of total billed charges,,0.17,14.23,
heparin 5000 units/mL Inj Sol 1 mL [KHKS],6361771,CDM,636,RC,J1644,HCPCS,63323-0262-06,NDC,Inpatient,1,ML,14.98,,,,80,,11.98,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.64,percent of total billed charges,,,95,,14.23,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,14.23,
albuterol-ipratropium 3 mg-0.5 mg/3 mL Sol [KHKS],6361773,CDM,250,RC,76204-0600-01,NDC,,,Outpatient,3,ML,6.89,,,,80,,5.51,percent of total billed charges,,,,85,5.86,percent of total billed charges,,,77.7,,5.35,percent of total billed charges,,,95,,6.54,percent of total billed charges,,,60,,4.13,percent of total billed charges,,4.13,6.54,
albuterol-ipratropium 3 mg-0.5 mg/3 mL Sol [KHKS],6361773,CDM,250,RC,76204-0600-01,NDC,,,Inpatient,3,ML,6.89,,,,80,,5.51,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.35,percent of total billed charges,,,95,,6.54,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.54,
meclizine 25 mg Tab [KHKS],6362390,CDM,250,RC,60687-0730-01,NDC,,,Outpatient,1,EA,2.57,,,,80,,2.05,percent of total billed charges,,,,85,2.18,percent of total billed charges,,,77.7,,2,percent of total billed charges,,,95,,2.44,percent of total billed charges,,,60,,1.54,percent of total billed charges,,1.54,2.44,
meclizine 25 mg Tab [KHKS],6362390,CDM,250,RC,60687-0730-01,NDC,,,Inpatient,1,EA,2.57,,,,80,,2.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2,percent of total billed charges,,,95,,2.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.44,
diltiazem 30 mg Tab [KHKS],6362391,CDM,250,RC,60687-0717-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
diltiazem 30 mg Tab [KHKS],6362391,CDM,250,RC,60687-0717-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
nystatin topical 100000 units/g Powd 15 gm [KHKS],6363996,CDM,250,RC,69315-0306-15,NDC,,,Outpatient,15,EA,69.84,,,,80,,55.87,percent of total billed charges,,,,85,59.36,percent of total billed charges,,,77.7,,54.27,percent of total billed charges,,,95,,66.35,percent of total billed charges,,,60,,41.9,percent of total billed charges,,41.9,66.35,
nystatin topical 100000 units/g Powd 15 gm [KHKS],6363996,CDM,250,RC,69315-0306-15,NDC,,,Inpatient,15,EA,69.84,,,,80,,55.87,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,54.27,percent of total billed charges,,,95,,66.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,66.35,
vancomycin 125 mg Cap [KHKS],6363997,CDM,250,RC,68180-0166-13,NDC,,,Outpatient,1,EA,93.92,,,,80,,75.13,percent of total billed charges,,,,85,79.83,percent of total billed charges,,,77.7,,72.97,percent of total billed charges,,,95,,89.22,percent of total billed charges,,,60,,56.35,percent of total billed charges,,56.35,89.22,
vancomycin 125 mg Cap [KHKS],6363997,CDM,250,RC,68180-0166-13,NDC,,,Inpatient,1,EA,93.92,,,,80,,75.13,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,72.97,percent of total billed charges,,,95,,89.22,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,89.22,
bumetanide 0.25 mg/mL Inj Sol 4 mL [KHKS],6363998,CDM,636,RC,J1939,HCPCS,72205-0101-07,NDC,Outpatient,4,ML,9.36,,,,80,,7.49,percent of total billed charges,,,,85,7.96,percent of total billed charges,,,77.7,,7.27,percent of total billed charges,,,95,,8.89,percent of total billed charges,,,60,,5.62,percent of total billed charges,,5.62,8.89,
bumetanide 0.25 mg/mL Inj Sol 4 mL [KHKS],6363998,CDM,636,RC,J1939,HCPCS,72205-0101-07,NDC,Inpatient,4,ML,9.36,,,,80,,7.49,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.27,percent of total billed charges,,,95,,8.89,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,8.89,
lidocaine-prilocaine Top 2.5%-2.5% Cream 5 gm [KHKS],6364633,CDM,250,RC,62332-0582-04,NDC,,,Outpatient,5,EA,27.54,,,,80,,22.03,percent of total billed charges,,,,85,23.41,percent of total billed charges,,,77.7,,21.4,percent of total billed charges,,,95,,26.16,percent of total billed charges,,,60,,16.52,percent of total billed charges,,16.52,26.16,
lidocaine-prilocaine Top 2.5%-2.5% Cream 5 gm [KHKS],6364633,CDM,250,RC,62332-0582-04,NDC,,,Inpatient,5,EA,27.54,,,,80,,22.03,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,21.4,percent of total billed charges,,,95,,26.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,26.16,
predniSONE 10 mg Tab [KHKS],6364634,CDM,250,RC,60687-0134-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
predniSONE 10 mg Tab [KHKS],6364634,CDM,250,RC,60687-0134-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
"pancrelipase 10,440 units-39,150 units-39,150 units Tab [KHKS]",6367151,CDM,250,RC,73562-0104-10,NDC,,,Outpatient,1,EA,13.89,,,,80,,11.11,percent of total billed charges,,,,85,11.81,percent of total billed charges,,,77.7,,10.79,percent of total billed charges,,,95,,13.2,percent of total billed charges,,,60,,8.33,percent of total billed charges,,8.33,13.2,
"pancrelipase 10,440 units-39,150 units-39,150 units Tab [KHKS]",6367151,CDM,250,RC,73562-0104-10,NDC,,,Inpatient,1,EA,13.89,,,,80,,11.11,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.79,percent of total billed charges,,,95,,13.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.2,
ropinirole 0.25 mg Tab [KHKS],6367361,CDM,250,RC,60687-0577-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
ropinirole 0.25 mg Tab [KHKS],6367361,CDM,250,RC,60687-0577-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
acetaminophen 160 mg/5 mL Susp UD 5 mL [KHKS],6367706,CDM,250,RC,68094-0231-62,NDC,,,Outpatient,5,ML,3.03,,,,80,,2.42,percent of total billed charges,,,,85,2.58,percent of total billed charges,,,77.7,,2.36,percent of total billed charges,,,95,,2.88,percent of total billed charges,,,60,,1.82,percent of total billed charges,,1.82,2.88,
acetaminophen 160 mg/5 mL Susp UD 5 mL [KHKS],6367706,CDM,250,RC,68094-0231-62,NDC,,,Inpatient,5,ML,3.03,,,,80,,2.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.36,percent of total billed charges,,,95,,2.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.88,
citalopram 20 mg Tab [KHKS],6368330,CDM,250,RC,76282-0629-90,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
citalopram 20 mg Tab [KHKS],6368330,CDM,250,RC,76282-0629-90,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
lactulose 10 g/15 mL Oral Syrup [KHKS],6371913,CDM,250,RC,45963-0439-65,NDC,,,Outpatient,30,ML,6.41,,,,80,,5.13,percent of total billed charges,,,,85,5.45,percent of total billed charges,,,77.7,,4.98,percent of total billed charges,,,95,,6.09,percent of total billed charges,,,60,,3.85,percent of total billed charges,,3.85,6.09,
lactulose 10 g/15 mL Oral Syrup [KHKS],6371913,CDM,250,RC,45963-0439-65,NDC,,,Inpatient,30,ML,6.41,,,,80,,5.13,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.98,percent of total billed charges,,,95,,6.09,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.09,
medroxyPROGESTERone 150 mg/mL IM Susp [KHKS],6372118,CDM,636,RC,J1050,HCPCS,00009-0746-30,NDC,Outpatient,1,ML,189.47,,,,80,,151.57,percent of total billed charges,,,,50,0.25,fee schedule,,,77.7,,147.22,percent of total billed charges,,,95,,179.99,percent of total billed charges,,,60,,113.68,percent of total billed charges,,0.25,179.99,
medroxyPROGESTERone 150 mg/mL IM Susp [KHKS],6372118,CDM,636,RC,J1050,HCPCS,00009-0746-30,NDC,Inpatient,1,ML,189.47,,,,80,,151.57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,147.22,percent of total billed charges,,,95,,179.99,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,179.99,
misoprostol 25mcg of a 100 mcg Tab [KHKS],6372138,CDM,250,RC,70954-0443-10QQ,NDC,,,Outpatient,1,EA,2.94,,,,80,,2.35,percent of total billed charges,,,,85,2.5,percent of total billed charges,,,77.7,,2.28,percent of total billed charges,,,95,,2.79,percent of total billed charges,,,60,,1.76,percent of total billed charges,,1.76,2.79,
misoprostol 25mcg of a 100 mcg Tab [KHKS],6372138,CDM,250,RC,70954-0443-10QQ,NDC,,,Inpatient,1,EA,2.94,,,,80,,2.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.28,percent of total billed charges,,,95,,2.79,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.79,
misoprostol 10 Tabs of 100 mcg = 1000 mcg Tab [KHKS],6372569,CDM,250,RC,70954-0443-10QZ,NDC,,,Outpatient,1,EA,30,,,,80,,24,percent of total billed charges,,,,85,25.5,percent of total billed charges,,,77.7,,23.31,percent of total billed charges,,,95,,28.5,percent of total billed charges,,,60,,18,percent of total billed charges,,18,28.5,
misoprostol 10 Tabs of 100 mcg = 1000 mcg Tab [KHKS],6372569,CDM,250,RC,70954-0443-10QZ,NDC,,,Inpatient,1,EA,30,,,,80,,24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,23.31,percent of total billed charges,,,95,,28.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,28.5,
promethazine 25 mg Oral Tab [KHKS],6374135,CDM,250,RC,00904-7304-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
promethazine 25 mg Oral Tab [KHKS],6374135,CDM,250,RC,00904-7304-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
prednisoLONE sodium phosphate 15 mg/5 mL Syringe Oral Liq (from 237 mL) [KHKS],6374137,CDM,250,RC,42799-0815-01,NDC,,,Outpatient,5,ML,4.68,,,,80,,3.75,percent of total billed charges,,,,85,3.98,percent of total billed charges,,,77.7,,3.64,percent of total billed charges,,,95,,4.45,percent of total billed charges,,,60,,2.81,percent of total billed charges,,2.81,4.45,
prednisoLONE sodium phosphate 15 mg/5 mL Syringe Oral Liq (from 237 mL) [KHKS],6374137,CDM,250,RC,42799-0815-01,NDC,,,Inpatient,5,ML,4.68,,,,80,,3.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.64,percent of total billed charges,,,95,,4.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.45,
buPROPion 150 mg/24 hours ER Tab [KHKS],6374138,CDM,250,RC,42806-0414-30,NDC,,,Outpatient,1,EA,12.93,,,,80,,10.34,percent of total billed charges,,,,85,10.99,percent of total billed charges,,,77.7,,10.04,percent of total billed charges,,,95,,12.28,percent of total billed charges,,,60,,7.76,percent of total billed charges,,7.76,12.28,
buPROPion 150 mg/24 hours ER Tab [KHKS],6374138,CDM,250,RC,42806-0414-30,NDC,,,Inpatient,1,EA,12.93,,,,80,,10.34,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.04,percent of total billed charges,,,95,,12.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,12.28,
predniSONE 2.5 mg Tab [KHKS],6374140,CDM,J7512,HCPCS,59651-0485-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,50,0.01,fee schedule,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,0.01,2.38,
predniSONE 2.5 mg Tab [KHKS],6374140,CDM,J7512,HCPCS,59651-0485-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
budesonide 0.5 mg/2 mL Inh Susp [KHKS],6375814,CDM,250,RC,68180-0984-30,NDC,,,Outpatient,1,ML,16.62,,,,80,,13.29,percent of total billed charges,,,,85,14.13,percent of total billed charges,,,77.7,,12.91,percent of total billed charges,,,95,,15.79,percent of total billed charges,,,60,,9.97,percent of total billed charges,,9.97,15.79,
budesonide 0.5 mg/2 mL Inh Susp [KHKS],6375814,CDM,250,RC,68180-0984-30,NDC,,,Inpatient,1,ML,16.62,,,,80,,13.29,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.91,percent of total billed charges,,,95,,15.79,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.79,
ALPRAZolam 0.25 mg Tab [KHKS],6377503,CDM,250,RC,00228-2027-10,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
ALPRAZolam 0.25 mg Tab [KHKS],6377503,CDM,250,RC,00228-2027-10,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
furosemide 20 mg Tab [KHKS],6378563,CDM,250,RC,64980-0562-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
furosemide 20 mg Tab [KHKS],6378563,CDM,250,RC,64980-0562-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
clopidogrel 75 mg Tab [KHKS],6378569,CDM,250,RC,16714-0052-11,NDC,,,Outpatient,1,EA,14.85,,,,80,,11.88,percent of total billed charges,,,,85,12.62,percent of total billed charges,,,77.7,,11.54,percent of total billed charges,,,95,,14.11,percent of total billed charges,,,60,,8.91,percent of total billed charges,,8.91,14.11,
clopidogrel 75 mg Tab [KHKS],6378569,CDM,250,RC,16714-0052-11,NDC,,,Inpatient,1,EA,14.85,,,,80,,11.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.54,percent of total billed charges,,,95,,14.11,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,14.11,
azithromycin 500. mg Powder-Inj,6380621,CDM,636,RC,J0456,HCPCS,70095-0025-02,NDC,Outpatient,1,EA,21.6,,,,80,,17.28,percent of total billed charges,,,,50,1.92,fee schedule,,,77.7,,16.78,percent of total billed charges,,,95,,20.52,percent of total billed charges,,,60,,12.96,percent of total billed charges,,1.92,20.52,
azithromycin 500. mg Powder-Inj,6380621,CDM,636,RC,J0456,HCPCS,70095-0025-02,NDC,Inpatient,1,EA,21.6,,,,80,,17.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,16.78,percent of total billed charges,,,95,,20.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,20.52,
dapagliflozin 5 mg Tab,6381513,CDM,250,RC,66993-0456-30,NDC,,,Outpatient,1,EA,66.38,,,,80,,53.1,percent of total billed charges,,,,85,56.42,percent of total billed charges,,,77.7,,51.57,percent of total billed charges,,,95,,63.06,percent of total billed charges,,,60,,39.83,percent of total billed charges,,39.83,63.06,
dapagliflozin 5 mg Tab,6381513,CDM,250,RC,66993-0456-30,NDC,,,Inpatient,1,EA,66.38,,,,80,,53.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,51.57,percent of total billed charges,,,95,,63.06,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,63.06,
nitrofurantoin macrocrystals-monohydrate 100 mg Cap,6381854,CDM,250,RC,00904-7137-61,NDC,,,Outpatient,1,EA,8.31,,,,80,,6.65,percent of total billed charges,,,,85,7.06,percent of total billed charges,,,77.7,,6.46,percent of total billed charges,,,95,,7.89,percent of total billed charges,,,60,,4.98,percent of total billed charges,,4.98,7.89,
nitrofurantoin macrocrystals-monohydrate 100 mg Cap,6381854,CDM,250,RC,00904-7137-61,NDC,,,Inpatient,1,EA,8.31,,,,80,,6.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.46,percent of total billed charges,,,95,,7.89,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.89,
potassium chloride 10. mEq Tab-ER,6381855,CDM,250,RC,00574-0275-11,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
potassium chloride 10. mEq Tab-ER,6381855,CDM,250,RC,00574-0275-11,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
arformoterol 15 mcg/2 mL Inh Sol [KHKS],6382872,CDM,250,RC,70756-0612-70,NDC,,,Outpatient,2,ML,61.08,,,,80,,48.87,percent of total billed charges,,,,85,51.92,percent of total billed charges,,,77.7,,47.46,percent of total billed charges,,,95,,58.03,percent of total billed charges,,,60,,36.65,percent of total billed charges,,36.65,58.03,
arformoterol 15 mcg/2 mL Inh Sol [KHKS],6382872,CDM,250,RC,70756-0612-70,NDC,,,Inpatient,2,ML,61.08,,,,80,,48.87,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,47.46,percent of total billed charges,,,95,,58.03,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,58.03,
ampicillin 250 mg Pow-Inj Vial [KHKS],6385449,CDM,636,RC,J0290,HCPCS,00781-9402-95,NDC,Outpatient,1,EA,12.57,,,,80,,10.06,percent of total billed charges,,,,50,0.65,fee schedule,,,77.7,,9.77,percent of total billed charges,,,95,,11.94,percent of total billed charges,,,60,,7.54,percent of total billed charges,,0.65,11.94,
ampicillin 250 mg Pow-Inj Vial [KHKS],6385449,CDM,636,RC,J0290,HCPCS,00781-9402-95,NDC,Inpatient,1,EA,12.57,,,,80,,10.06,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.77,percent of total billed charges,,,95,,11.94,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.94,
famotidine 10 mg Tab [KHKS],6385968,CDM,250,RC,70677-1102-03,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
famotidine 10 mg Tab [KHKS],6385968,CDM,250,RC,70677-1102-03,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
lidocaine-prilocaine Top 2.5%-2.5% Cream 30 gm[KHKS],6387410,CDM,250,RC,00168-0357-30,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
lidocaine-prilocaine Top 2.5%-2.5% Cream 30 gm[KHKS],6387410,CDM,250,RC,00168-0357-30,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
melatonin 3 mg Tab [KHKS],6387411,CDM,250,RC,20555-0036-00,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
melatonin 3 mg Tab [KHKS],6387411,CDM,250,RC,20555-0036-00,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
piperacillin-tazobactam 3.375 g IV Inj Vial [KHKS],6388855,CDM,636,RC,J2543,HCPCS,72485-0403-10,NDC,Outpatient,1,EA,51.42,,,,80,,41.14,percent of total billed charges,,,,50,1.15,fee schedule,,,77.7,,39.95,percent of total billed charges,,,95,,48.85,percent of total billed charges,,,60,,30.85,percent of total billed charges,,1.15,48.85,
piperacillin-tazobactam 3.375 g IV Inj Vial [KHKS],6388855,CDM,636,RC,J2543,HCPCS,72485-0403-10,NDC,Inpatient,1,EA,51.42,,,,80,,41.14,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,39.95,percent of total billed charges,,,95,,48.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,48.85,
nalbuphine 10 mg/mL Inj Sol 10 mL [KHKS],6389298,CDM,636,RC,J2300,HCPCS,00409-1464-01,NDC,Outpatient,10,ML,159.6,,,,80,,127.68,percent of total billed charges,,,,50,1.79,fee schedule,,,77.7,,124.01,percent of total billed charges,,,95,,151.62,percent of total billed charges,,,60,,95.76,percent of total billed charges,,1.79,151.62,
nalbuphine 10 mg/mL Inj Sol 10 mL [KHKS],6389298,CDM,636,RC,J2300,HCPCS,00409-1464-01,NDC,Inpatient,10,ML,159.6,,,,80,,127.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,124.01,percent of total billed charges,,,95,,151.62,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,151.62,
PHENobarbital 65 mg/mL Inj Sol 1 mL [KHKS],6389762,CDM,636,RC,J2560,HCPCS,42494-0441-25,NDC,Outpatient,1,ML,49.77,,,,80,,39.82,percent of total billed charges,,,,50,29.49,fee schedule,,,77.7,,38.68,percent of total billed charges,,,95,,47.29,percent of total billed charges,,,60,,29.86,percent of total billed charges,,29.49,47.29,
PHENobarbital 65 mg/mL Inj Sol 1 mL [KHKS],6389762,CDM,636,RC,J2560,HCPCS,42494-0441-25,NDC,Inpatient,1,ML,49.77,,,,80,,39.82,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,38.68,percent of total billed charges,,,95,,47.29,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,47.29,
phenytoin 100 mg ER Cap [KHKS],6390113,CDM,250,RC,00071-0369-40,NDC,,,Outpatient,1,EA,6.68,,,,80,,5.35,percent of total billed charges,,,,85,5.68,percent of total billed charges,,,77.7,,5.19,percent of total billed charges,,,95,,6.35,percent of total billed charges,,,60,,4.01,percent of total billed charges,,4.01,6.35,
phenytoin 100 mg ER Cap [KHKS],6390113,CDM,250,RC,00071-0369-40,NDC,,,Inpatient,1,EA,6.68,,,,80,,5.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.19,percent of total billed charges,,,95,,6.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.35,
methylPREDNISolone acetate 80 mg/mL Inj Susp [KHKS],6390116,CDM,636,RC,J1010,HCPCS,70121-1574-05,NDC,Outpatient,1,ML,58.75,,,,80,,47,percent of total billed charges,,,,85,49.94,percent of total billed charges,,,77.7,,45.65,percent of total billed charges,,,95,,55.81,percent of total billed charges,,,60,,35.25,percent of total billed charges,,35.25,55.81,
methylPREDNISolone acetate 80 mg/mL Inj Susp [KHKS],6390116,CDM,636,RC,J1010,HCPCS,70121-1574-05,NDC,Inpatient,1,ML,58.75,,,,80,,47,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,45.65,percent of total billed charges,,,95,,55.81,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,55.81,
orphenadrine 30 mg/mL Inj Sol 2 mL [KHKS],6390117,CDM,636,RC,J2360,HCPCS,25021-0651-02,NDC,Outpatient,2,ML,43.2,,,,80,,34.56,percent of total billed charges,,,,50,3.46,fee schedule,,,77.7,,33.57,percent of total billed charges,,,95,,41.04,percent of total billed charges,,,60,,25.92,percent of total billed charges,,3.46,41.04,
orphenadrine 30 mg/mL Inj Sol 2 mL [KHKS],6390117,CDM,636,RC,J2360,HCPCS,25021-0651-02,NDC,Inpatient,2,ML,43.2,,,,80,,34.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,33.57,percent of total billed charges,,,95,,41.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,41.04,
ampicillin-sulbactam 3 g Inj Pow [KHKS],6390118,CDM,636,RC,J0295,HCPCS,00641-6117-10,NDC,Outpatient,1,EA,27.43,,,,80,,21.95,percent of total billed charges,,,,50,1.44,fee schedule,,,77.7,,21.31,percent of total billed charges,,,95,,26.06,percent of total billed charges,,,60,,16.46,percent of total billed charges,,1.44,26.06,
ampicillin-sulbactam 3 g Inj Pow [KHKS],6390118,CDM,636,RC,J0295,HCPCS,00641-6117-10,NDC,Inpatient,1,EA,27.43,,,,80,,21.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,21.31,percent of total billed charges,,,95,,26.06,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,26.06,
traZODone 50 mg Tab [KHKS],6390512,CDM,250,RC,60687-0443-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
traZODone 50 mg Tab [KHKS],6390512,CDM,250,RC,60687-0443-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
predniSONE 10 mg Tab [KHKS],6391404,CDM,250,RC,00054-9817-25,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
predniSONE 10 mg Tab [KHKS],6391404,CDM,250,RC,00054-9817-25,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
predniSONE 10 mg Tab [KHKS],6392264,CDM,250,RC,00904-6923-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
predniSONE 10 mg Tab [KHKS],6392264,CDM,250,RC,00904-6923-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
finasteride 5 mg Tab [KHKS],6393564,CDM,250,RC,50268-0314-15,NDC,,,Outpatient,1,EA,9.38,,,,80,,7.5,percent of total billed charges,,,,85,7.97,percent of total billed charges,,,77.7,,7.29,percent of total billed charges,,,95,,8.91,percent of total billed charges,,,60,,5.63,percent of total billed charges,,5.63,8.91,
finasteride 5 mg Tab [KHKS],6393564,CDM,250,RC,50268-0314-15,NDC,,,Inpatient,1,EA,9.38,,,,80,,7.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.29,percent of total billed charges,,,95,,8.91,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,8.91,
chlorthalidone 25 mg Tab [KHKS],6394632,CDM,250,RC,43598-0170-01,NDC,,,Outpatient,1,EA,3.62,,,,80,,2.9,percent of total billed charges,,,,85,3.08,percent of total billed charges,,,77.7,,2.81,percent of total billed charges,,,95,,3.44,percent of total billed charges,,,60,,2.17,percent of total billed charges,,2.17,3.44,
chlorthalidone 25 mg Tab [KHKS],6394632,CDM,250,RC,43598-0170-01,NDC,,,Inpatient,1,EA,3.62,,,,80,,2.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.81,percent of total billed charges,,,95,,3.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.44,
chlorthalidone 25 mg Tab,6395053,CDM,250,RC,50268-0167-15,NDC,,,Outpatient,1,EA,6.89,,,,80,,5.51,percent of total billed charges,,,,85,5.86,percent of total billed charges,,,77.7,,5.35,percent of total billed charges,,,95,,6.54,percent of total billed charges,,,60,,4.13,percent of total billed charges,,4.13,6.54,
chlorthalidone 25 mg Tab,6395053,CDM,250,RC,50268-0167-15,NDC,,,Inpatient,1,EA,6.89,,,,80,,5.51,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.35,percent of total billed charges,,,95,,6.54,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.54,
ciprofloxacin 500 mg Tab,6395402,CDM,250,RC,00904-7243-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
ciprofloxacin 500 mg Tab,6395402,CDM,250,RC,00904-7243-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
ofloxacin otic 0.3% Sol,6395425,CDM,250,RC,70756-0609-15,NDC,,,Outpatient,5,EA,354.02,,,,80,,283.21,percent of total billed charges,,,,85,300.92,percent of total billed charges,,,77.7,,275.07,percent of total billed charges,,,95,,336.31,percent of total billed charges,,,60,,212.41,percent of total billed charges,,212.41,336.31,
ofloxacin otic 0.3% Sol,6395425,CDM,250,RC,70756-0609-15,NDC,,,Inpatient,5,EA,354.02,,,,80,,283.21,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,275.07,percent of total billed charges,,,95,,336.31,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,336.31,
azithromycin 250 mg Tab [KHKS],6396048,CDM,250,RC,00904-7350-06,NDC,,,Outpatient,1,EA,4.45,,,,80,,3.56,percent of total billed charges,,,,85,3.78,percent of total billed charges,,,77.7,,3.45,percent of total billed charges,,,95,,4.22,percent of total billed charges,,,60,,2.67,percent of total billed charges,,2.67,4.22,
azithromycin 250 mg Tab [KHKS],6396048,CDM,250,RC,00904-7350-06,NDC,,,Inpatient,1,EA,4.45,,,,80,,3.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.45,percent of total billed charges,,,95,,4.22,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.22,
prednisoLONE sodium phosphate 15 mg/5 mL Syringe Oral Liq (from 237 mL) [KHKS],6396241,CDM,250,RC,69238-2122-09,NDC,,,Outpatient,5,ML,4.68,,,,80,,3.75,percent of total billed charges,,,,85,3.98,percent of total billed charges,,,77.7,,3.64,percent of total billed charges,,,95,,4.45,percent of total billed charges,,,60,,2.81,percent of total billed charges,,2.81,4.45,
prednisoLONE sodium phosphate 15 mg/5 mL Syringe Oral Liq (from 237 mL) [KHKS],6396241,CDM,250,RC,69238-2122-09,NDC,,,Inpatient,5,ML,4.68,,,,80,,3.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.64,percent of total billed charges,,,95,,4.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.45,
potassium chloride 20 mEq/15 mL Oral Liq 15 mL [KHKS],6396370,CDM,250,RC,63739-0724-50,NDC,,,Outpatient,15,ML,29.7,,,,80,,23.76,percent of total billed charges,,,,85,25.25,percent of total billed charges,,,77.7,,23.08,percent of total billed charges,,,95,,28.22,percent of total billed charges,,,60,,17.82,percent of total billed charges,,17.82,28.22,
potassium chloride 20 mEq/15 mL Oral Liq 15 mL [KHKS],6396370,CDM,250,RC,63739-0724-50,NDC,,,Inpatient,15,ML,29.7,,,,80,,23.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,23.08,percent of total billed charges,,,95,,28.22,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,28.22,
cefTRIAXone 1 g Inj Vial [KHKS],6398226,CDM,636,RC,J0696,HCPCS,00409-7332-01,NDC,Outpatient,1,EA,5.48,,,,80,,4.39,percent of total billed charges,,,,50,0.4,fee schedule,,,77.7,,4.26,percent of total billed charges,,,95,,5.21,percent of total billed charges,,,60,,3.29,percent of total billed charges,,0.4,5.21,
cefTRIAXone 1 g Inj Vial [KHKS],6398226,CDM,636,RC,J0696,HCPCS,00409-7332-01,NDC,Inpatient,1,EA,5.48,,,,80,,4.39,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.26,percent of total billed charges,,,95,,5.21,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.21,
insulin regular human recombinant 100 units/mL Inj Sol 10 mL MDV [KHKS],6398863,CDM,636,RC,J1815,HCPCS,00169-1833-11,NDC,Outpatient,1,ML,17.35,,,,80,,13.88,percent of total billed charges,,,,50,0.58,fee schedule,,,77.7,,13.48,percent of total billed charges,,,95,,16.48,percent of total billed charges,,,60,,10.41,percent of total billed charges,,0.58,16.48,
insulin regular human recombinant 100 units/mL Inj Sol 10 mL MDV [KHKS],6398863,CDM,636,RC,J1815,HCPCS,00169-1833-11,NDC,Inpatient,1,ML,17.35,,,,80,,13.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,13.48,percent of total billed charges,,,95,,16.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,16.48,
aprepitant 40 mg Cap,6399143,CDM,250,RC,68462-0583-85,NDC,,,Outpatient,1,EA,247.36,,,,80,,197.88,percent of total billed charges,,,,85,210.26,percent of total billed charges,,,77.7,,192.2,percent of total billed charges,,,95,,234.99,percent of total billed charges,,,60,,148.41,percent of total billed charges,,148.41,234.99,
aprepitant 40 mg Cap,6399143,CDM,250,RC,68462-0583-85,NDC,,,Inpatient,1,EA,247.36,,,,80,,197.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,192.2,percent of total billed charges,,,95,,234.99,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,234.99,
furosemide 10 mg/mL Inj Sol 4 mL [KHKS],6401365,CDM,636,RC,J1940,HCPCS,00409-6102-26,NDC,Outpatient,4,ML,10.56,,,,80,,8.45,percent of total billed charges,,,,50,0.42,fee schedule,,,77.7,,8.21,percent of total billed charges,,,95,,10.03,percent of total billed charges,,,60,,6.34,percent of total billed charges,,0.42,10.03,
furosemide 10 mg/mL Inj Sol 4 mL [KHKS],6401365,CDM,636,RC,J1940,HCPCS,00409-6102-26,NDC,Inpatient,4,ML,10.56,,,,80,,8.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.21,percent of total billed charges,,,95,,10.03,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.03,
celecoxib 100 mg Cap [KHKS],6402234,CDM,250,RC,60687-0436-01,NDC,,,Outpatient,1,EA,13.86,,,,80,,11.09,percent of total billed charges,,,,85,11.78,percent of total billed charges,,,77.7,,10.77,percent of total billed charges,,,95,,13.16,percent of total billed charges,,,60,,8.31,percent of total billed charges,,8.31,13.16,
celecoxib 100 mg Cap [KHKS],6402234,CDM,250,RC,60687-0436-01,NDC,,,Inpatient,1,EA,13.86,,,,80,,11.09,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.77,percent of total billed charges,,,95,,13.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.16,
montelukast 10 mg Tab [KHKS],6402374,CDM,250,RC,00904-6808-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
montelukast 10 mg Tab [KHKS],6402374,CDM,250,RC,00904-6808-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
octreotide 100 mcg/mL Inj Sol 1 mL [KHKS],6402379,CDM,636,RC,J2354,HCPCS,67457-0245-01,NDC,Outpatient,1,ML,28.44,,,,80,,22.75,percent of total billed charges,,,,50,0.91,fee schedule,,,77.7,,22.1,percent of total billed charges,,,95,,27.02,percent of total billed charges,,,60,,17.06,percent of total billed charges,,0.91,27.02,
octreotide 100 mcg/mL Inj Sol 1 mL [KHKS],6402379,CDM,636,RC,J2354,HCPCS,67457-0245-01,NDC,Inpatient,1,ML,28.44,,,,80,,22.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,22.1,percent of total billed charges,,,95,,27.02,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,27.02,
prochlorperazine 5 mg/mL Inj Sol 2 mL [KHKS],6403445,CDM,636,RC,J0780,HCPCS,25021-0790-02,NDC,Outpatient,2,ML,19.08,,,,80,,15.26,percent of total billed charges,,,,50,1.9,fee schedule,,,77.7,,14.83,percent of total billed charges,,,95,,18.13,percent of total billed charges,,,60,,11.45,percent of total billed charges,,1.9,18.13,
prochlorperazine 5 mg/mL Inj Sol 2 mL [KHKS],6403445,CDM,636,RC,J0780,HCPCS,25021-0790-02,NDC,Inpatient,2,ML,19.08,,,,80,,15.26,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.83,percent of total billed charges,,,95,,18.13,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,18.13,
labetalol 100 mg Tab [KHKS],6403756,CDM,250,RC,60687-0439-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
labetalol 100 mg Tab [KHKS],6403756,CDM,250,RC,60687-0439-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
allopurinol 100 mg Tab [KHKS],6404155,CDM,250,RC,00904-7041-61,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
allopurinol 100 mg Tab [KHKS],6404155,CDM,250,RC,00904-7041-61,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
FLUoxetine 10 mg Cap [KHKS],6404156,CDM,250,RC,16714-0720-02,NDC,,,Outpatient,1,EA,7.79,,,,80,,6.24,percent of total billed charges,,,,85,6.62,percent of total billed charges,,,77.7,,6.06,percent of total billed charges,,,95,,7.41,percent of total billed charges,,,60,,4.68,percent of total billed charges,,4.68,7.41,
FLUoxetine 10 mg Cap [KHKS],6404156,CDM,250,RC,16714-0720-02,NDC,,,Inpatient,1,EA,7.79,,,,80,,6.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.06,percent of total billed charges,,,95,,7.41,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,7.41,
insulin lispro 100 units/mL Sol 10 mL [KHKS],6405718,CDM,636,RC,J1815,HCPCS,00002-7737-01,NDC,Outpatient,1,ML,29.67,,,,80,,23.73,percent of total billed charges,,,,50,0.58,fee schedule,,,77.7,,23.05,percent of total billed charges,,,95,,28.18,percent of total billed charges,,,60,,17.8,percent of total billed charges,,0.58,28.18,
insulin lispro 100 units/mL Sol 10 mL [KHKS],6405718,CDM,636,RC,J1815,HCPCS,00002-7737-01,NDC,Inpatient,1,ML,29.67,,,,80,,23.73,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,23.05,percent of total billed charges,,,95,,28.18,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,28.18,
HYDROmorphone 1 mg/mL Sol 1 mL [KHKS],6407693,CDM,636,RC,J1171,HCPCS,00409-1283-31,NDC,Outpatient,1,ML,9.36,,,,80,,7.49,percent of total billed charges,,,,85,7.96,percent of total billed charges,,,77.7,,7.27,percent of total billed charges,,,95,,8.89,percent of total billed charges,,,60,,5.61,percent of total billed charges,,5.61,8.89,
HYDROmorphone 1 mg/mL Sol 1 mL [KHKS],6407693,CDM,636,RC,J1171,HCPCS,00409-1283-31,NDC,Inpatient,1,ML,9.36,,,,80,,7.49,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.27,percent of total billed charges,,,95,,8.89,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,8.89,
pantoprazole 40 mg IV Pow-Inj (Hikma) [KHKS],6408356,CDM,636,RC,J2471,HCPCS,00143-9284-10,NDC,Outpatient,1,EA,23.4,,,,80,,18.72,percent of total billed charges,,,,85,19.89,percent of total billed charges,,,77.7,,18.18,percent of total billed charges,,,95,,22.23,percent of total billed charges,,,60,,14.04,percent of total billed charges,,14.04,22.23,
pantoprazole 40 mg IV Pow-Inj (Hikma) [KHKS],6408356,CDM,636,RC,J2471,HCPCS,00143-9284-10,NDC,Inpatient,1,EA,23.4,,,,80,,18.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,18.18,percent of total billed charges,,,95,,22.23,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,22.23,
EPINEPHrine 1 mg/mL Inj Sol 10 mL [KHKS],6408389,CDM,636,RC,J0171,HCPCS,54288-0600-01,NDC,Outpatient,10,ML,136.41,,,,80,,109.13,percent of total billed charges,,,,50,0.47,fee schedule,,,77.7,,105.99,percent of total billed charges,,,95,,129.59,percent of total billed charges,,,60,,81.85,percent of total billed charges,,0.47,129.59,
EPINEPHrine 1 mg/mL Inj Sol 10 mL [KHKS],6408389,CDM,636,RC,J0171,HCPCS,54288-0600-01,NDC,Inpatient,10,ML,136.41,,,,80,,109.13,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,105.99,percent of total billed charges,,,95,,129.59,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,129.59,
propranolol 10 mg Tab [KHKS],6411356,CDM,250,RC,60687-0587-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
propranolol 10 mg Tab [KHKS],6411356,CDM,250,RC,60687-0587-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
enoxaparin 30 mg/0.3 mL Sol Syringe [KHKS],6414166,CDM,636,RC,J1650,HCPCS,00955-1003-10,NDC,Outpatient,0.3,ML,23.09,,,,80,,18.48,percent of total billed charges,,,,50,0.52,fee schedule,,,77.7,,17.94,percent of total billed charges,,,95,,21.94,percent of total billed charges,,,60,,13.86,percent of total billed charges,,0.52,21.94,
enoxaparin 30 mg/0.3 mL Sol Syringe [KHKS],6414166,CDM,636,RC,J1650,HCPCS,00955-1003-10,NDC,Inpatient,0.3,ML,23.09,,,,80,,18.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,17.94,percent of total billed charges,,,95,,21.94,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,21.94,
carvedilol 6.25 mg Tab [KHKS],6414167,CDM,250,RC,68084-0854-01,NDC,,,Outpatient,1,EA,5.85,,,,80,,4.68,percent of total billed charges,,,,85,4.97,percent of total billed charges,,,77.7,,4.54,percent of total billed charges,,,95,,5.56,percent of total billed charges,,,60,,3.51,percent of total billed charges,,3.51,5.56,
carvedilol 6.25 mg Tab [KHKS],6414167,CDM,250,RC,68084-0854-01,NDC,,,Inpatient,1,EA,5.85,,,,80,,4.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.54,percent of total billed charges,,,95,,5.56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.56,
"influenza virus vaccine, inactivated PF trivalent (Fluarix PF 24-05) Susp 0.5 mL [KHKS]",6414734,CDM,636,RC,90656,CPT,58160-0884-52,NDC,Outpatient,0.5,ML,56.49,,,,80,,45.19,percent of total billed charges,,,,50,12.38,fee schedule,,,77.7,,43.89,percent of total billed charges,,,95,,53.67,percent of total billed charges,,,60,,33.89,percent of total billed charges,,33.89,53.67,
"influenza virus vaccine, inactivated PF trivalent (Fluarix PF 24-05) Susp 0.5 mL [KHKS]",6414734,CDM,636,RC,90656,CPT,58160-0884-52,NDC,Inpatient,0.5,ML,56.49,,,,80,,45.19,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,43.89,percent of total billed charges,,,95,,53.67,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,53.67,
polyethylene glycol 3350 Oral Pwdr for Recon 238 gm [KHKS],6414735,CDM,250,RC,70677-1068-01,NDC,,,Outpatient,238,EA,39.27,,,,80,,31.42,percent of total billed charges,,,,85,33.38,percent of total billed charges,,,77.7,,30.51,percent of total billed charges,,,95,,37.31,percent of total billed charges,,,60,,23.56,percent of total billed charges,,23.56,37.31,
polyethylene glycol 3350 Oral Pwdr for Recon 238 gm [KHKS],6414735,CDM,250,RC,70677-1068-01,NDC,,,Inpatient,238,EA,39.27,,,,80,,31.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,30.51,percent of total billed charges,,,95,,37.31,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,37.31,
ciprofloxacin 400 mg/200 mL IV PREMIX Sol [KHKS],6415313,CDM,636,RC,J0744,HCPCS,25021-0192-87,NDC,Outpatient,200,ML,25.16,,,,80,,20.13,percent of total billed charges,,,,50,0.82,fee schedule,,,77.7,,19.55,percent of total billed charges,,,95,,23.91,percent of total billed charges,,,60,,15.1,percent of total billed charges,,0.82,23.91,
ciprofloxacin 400 mg/200 mL IV PREMIX Sol [KHKS],6415313,CDM,636,RC,J0744,HCPCS,25021-0192-87,NDC,Inpatient,200,ML,25.16,,,,80,,20.13,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.55,percent of total billed charges,,,95,,23.91,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,23.91,
tetanus immune globulin 250 units/mL Sol 1 mL *NON-FORM* [KHKS],6415674,CDM,636,RC,J1670,HCPCS,13533-0634-02,NDC,Outpatient,1,ML,1321.07,,,,80,,1056.85,percent of total billed charges,,,,50,338.08,fee schedule,,,77.7,,1026.47,percent of total billed charges,,,95,,1255.01,percent of total billed charges,,,60,,792.64,percent of total billed charges,,338.08,1255.01,
tetanus immune globulin 250 units/mL Sol 1 mL *NON-FORM* [KHKS],6415674,CDM,636,RC,J1670,HCPCS,13533-0634-02,NDC,Inpatient,1,ML,1321.07,,,,80,,1056.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1026.47,percent of total billed charges,,,95,,1255.01,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1255.01,
sodium chloride 0.9% FLUSH SYG 5 mL IN 10 mL [KHKS],6415939,CDM,250,RC,63807-0000-53,NDC,,,Outpatient,5,ML,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
sodium chloride 0.9% FLUSH SYG 5 mL IN 10 mL [KHKS],6415939,CDM,250,RC,63807-0000-53,NDC,,,Inpatient,5,ML,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
enalapril 5 mg Tab [KHKS],6416590,CDM,250,RC,16714-0443-01,NDC,,,Outpatient,1,EA,4.55,,,,80,,3.64,percent of total billed charges,,,,85,3.87,percent of total billed charges,,,77.7,,3.53,percent of total billed charges,,,95,,4.32,percent of total billed charges,,,60,,2.73,percent of total billed charges,,2.73,4.32,
enalapril 5 mg Tab [KHKS],6416590,CDM,250,RC,16714-0443-01,NDC,,,Inpatient,1,EA,4.55,,,,80,,3.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.53,percent of total billed charges,,,95,,4.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.32,
dexamethasone 1 mg Tab [KHKS],6416940,CDM,250,RC,72578-0166-01,NDC,,,Outpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,85,2.13,percent of total billed charges,,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,60,,1.5,percent of total billed charges,,1.5,2.38,
dexamethasone 1 mg Tab [KHKS],6416940,CDM,250,RC,72578-0166-01,NDC,,,Inpatient,1,EA,2.5,,,,80,,2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.94,percent of total billed charges,,,95,,2.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.38,
metolazone 2.5 mg Tab [KHKS],6419011,CDM,250,RC,62332-0532-31,NDC,,,Outpatient,1,EA,6.22,,,,80,,4.98,percent of total billed charges,,,,85,5.29,percent of total billed charges,,,77.7,,4.83,percent of total billed charges,,,95,,5.91,percent of total billed charges,,,60,,3.73,percent of total billed charges,,3.73,5.91,
metolazone 2.5 mg Tab [KHKS],6419011,CDM,250,RC,62332-0532-31,NDC,,,Inpatient,1,EA,6.22,,,,80,,4.98,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.83,percent of total billed charges,,,95,,5.91,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.91,
methylphenidate 10 mg Tab [KHKS],6420062,CDM,250,RC,00115-1801-01,NDC,,,Outpatient,1,EA,3,,,,80,,2.4,percent of total billed charges,,,,85,2.55,percent of total billed charges,,,77.7,,2.33,percent of total billed charges,,,95,,2.85,percent of total billed charges,,,60,,1.8,percent of total billed charges,,1.8,2.85,
methylphenidate 10 mg Tab [KHKS],6420062,CDM,250,RC,00115-1801-01,NDC,,,Inpatient,1,EA,3,,,,80,,2.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.33,percent of total billed charges,,,95,,2.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.85,
ampicillin 250 mg Pow-Inj Vial [KHKS],6420825,CDM,636,RC,J0290,HCPCS,00781-3402-95,NDC,Outpatient,1,EA,12.56,,,,80,,10.05,percent of total billed charges,,,,50,0.65,fee schedule,,,77.7,,9.76,percent of total billed charges,,,95,,11.93,percent of total billed charges,,,60,,7.53,percent of total billed charges,,0.65,11.93,
ampicillin 250 mg Pow-Inj Vial [KHKS],6420825,CDM,636,RC,J0290,HCPCS,00781-3402-95,NDC,Inpatient,1,EA,12.56,,,,80,,10.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.76,percent of total billed charges,,,95,,11.93,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.93,
arformoterol 15 mcg/2 mL Inh Sol [KHKS],6422254,CDM,250,RC,72603-0208-30,NDC,,,Outpatient,2,ML,61.9,,,,80,,49.52,percent of total billed charges,,,,85,52.62,percent of total billed charges,,,77.7,,48.1,percent of total billed charges,,,95,,58.8,percent of total billed charges,,,60,,37.14,percent of total billed charges,,37.14,58.8,
arformoterol 15 mcg/2 mL Inh Sol [KHKS],6422254,CDM,250,RC,72603-0208-30,NDC,,,Inpatient,2,ML,61.9,,,,80,,49.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,48.1,percent of total billed charges,,,95,,58.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,58.8,
"influenza virus vaccine, inactivated high-dose PF trivalent (Fluzone HD PF 24-25) Susp 0.5 mL [KHKS]",6422255,CDM,636,RC,90662,CPT,49281-0124-65,NDC,Outpatient,0.5,ML,198.39,,,,80,,158.71,percent of total billed charges,,,,50,43.81,fee schedule,,,77.7,,154.15,percent of total billed charges,,,95,,188.47,percent of total billed charges,,,60,,119.03,percent of total billed charges,,119.03,188.47,
"influenza virus vaccine, inactivated high-dose PF trivalent (Fluzone HD PF 24-25) Susp 0.5 mL [KHKS]",6422255,CDM,636,RC,90662,CPT,49281-0124-65,NDC,Inpatient,0.5,ML,198.39,,,,80,,158.71,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,154.15,percent of total billed charges,,,95,,188.47,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,188.47,
valACYclovir 1 gm Oral Tab [KHKS],6422758,CDM,250,RC,16714-0697-03,NDC,,,Outpatient,1,EA,34.86,,,,80,,27.89,percent of total billed charges,,,,85,29.63,percent of total billed charges,,,77.7,,27.09,percent of total billed charges,,,95,,33.12,percent of total billed charges,,,60,,20.92,percent of total billed charges,,20.92,33.12,
valACYclovir 1 gm Oral Tab [KHKS],6422758,CDM,250,RC,16714-0697-03,NDC,,,Inpatient,1,EA,34.86,,,,80,,27.89,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,27.09,percent of total billed charges,,,95,,33.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,33.12,
THP VALACYCLOVIR 1 GM ORAL TAB #6 [KHKS],6422759,CDM,253,RC,16714-0697-03QQ,NDC,,,Outpatient,1,EA,122.01,,,,80,,97.61,percent of total billed charges,,,,85,103.71,percent of total billed charges,,,77.7,,94.8,percent of total billed charges,,,95,,115.91,percent of total billed charges,,,60,,73.21,percent of total billed charges,,73.21,115.91,
THP VALACYCLOVIR 1 GM ORAL TAB #6 [KHKS],6422759,CDM,253,RC,16714-0697-03QQ,NDC,,,Inpatient,1,EA,122.01,,,,80,,97.61,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,94.8,percent of total billed charges,,,95,,115.91,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,115.91,
primidone 50 mg Oral Tab [KHKS],6433469,CDM,250,RC,50268-0686-15,NDC,,,Outpatient,1,EA,2.86,,,,80,,2.29,percent of total billed charges,,,,85,2.43,percent of total billed charges,,,77.7,,2.22,percent of total billed charges,,,95,,2.72,percent of total billed charges,,,60,,1.72,percent of total billed charges,,1.72,2.72,
primidone 50 mg Oral Tab [KHKS],6433469,CDM,250,RC,50268-0686-15,NDC,,,Inpatient,1,EA,2.86,,,,80,,2.29,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.22,percent of total billed charges,,,95,,2.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.72,
benzocaine-menthol Top 20%-0.5% Spray 78 gm [KHKS],6434977,CDM,250,RC,16864-0680-01,NDC,,,Outpatient,78,EA,19.3,,,,80,,15.44,percent of total billed charges,,,,85,16.41,percent of total billed charges,,,77.7,,14.99,percent of total billed charges,,,95,,18.33,percent of total billed charges,,,60,,11.58,percent of total billed charges,,11.58,18.33,
benzocaine-menthol Top 20%-0.5% Spray 78 gm [KHKS],6434977,CDM,250,RC,16864-0680-01,NDC,,,Inpatient,78,EA,19.3,,,,80,,15.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.99,percent of total billed charges,,,95,,18.33,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,18.33,
RHo (D) immune globulin 1500 intl units/2 mL Inj Sol [KHKS],6435403,CDM,636,RC,J2791,HCPCS,44206-0300-01,NDC,Outpatient,2,ML,370.89,,,,80,,296.71,percent of total billed charges,,,,50,3.2,fee schedule,,,77.7,,288.18,percent of total billed charges,,,95,,352.34,percent of total billed charges,,,60,,222.53,percent of total billed charges,,3.2,352.34,
RHo (D) immune globulin 1500 intl units/2 mL Inj Sol [KHKS],6435403,CDM,636,RC,J2791,HCPCS,44206-0300-01,NDC,Inpatient,2,ML,370.89,,,,80,,296.71,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,288.18,percent of total billed charges,,,95,,352.34,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,352.34,
SARS-CoV-2 (COVID-19) mRNA-LNP vaccine (Spikevax 24-25) (12 YR+) (cvx 312) PF 50 mcg/0.5 mL Susp [KHKS],6436347,CDM,636,RC,91322,CPT,80777-0110-96,NDC,Outpatient,0.5,ML,382.86,,,,80,,306.29,percent of total billed charges,,,,85,325.43,percent of total billed charges,,,77.7,,297.48,percent of total billed charges,,,95,,363.72,percent of total billed charges,,,60,,229.72,percent of total billed charges,,229.72,363.72,
SARS-CoV-2 (COVID-19) mRNA-LNP vaccine (Spikevax 24-25) (12 YR+) (cvx 312) PF 50 mcg/0.5 mL Susp [KHKS],6436347,CDM,636,RC,91322,CPT,80777-0110-96,NDC,Inpatient,0.5,ML,382.86,,,,80,,306.29,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,297.48,percent of total billed charges,,,95,,363.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,363.72,
albumin human 25% IV Sol 100 mL [KHKS],6442972,CDM,636,RC,P9047,HCPCS,68982-0643-02,NDC,Outpatient,100,ML,258.19,,,,80,,206.55,percent of total billed charges,,,,50,34.96,fee schedule,,,77.7,,200.61,percent of total billed charges,,,95,,245.28,percent of total billed charges,,,60,,154.91,percent of total billed charges,,34.96,245.28,
albumin human 25% IV Sol 100 mL [KHKS],6442972,CDM,636,RC,P9047,HCPCS,68982-0643-02,NDC,Inpatient,100,ML,258.19,,,,80,,206.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,200.61,percent of total billed charges,,,95,,245.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,245.28,
diazepam 5-7.5-10 mg rectal kit [KHKS],6444065,CDM,250,RC,43386-0280-01,NDC,,,Outpatient,1,EA,673.51,,,,80,,538.81,percent of total billed charges,,,,85,572.48,percent of total billed charges,,,77.7,,523.32,percent of total billed charges,,,95,,639.84,percent of total billed charges,,,60,,404.11,percent of total billed charges,,404.11,639.84,
diazepam 5-7.5-10 mg rectal kit [KHKS],6444065,CDM,250,RC,43386-0280-01,NDC,,,Inpatient,1,EA,673.51,,,,80,,538.81,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,523.32,percent of total billed charges,,,95,,639.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,639.84,
L&D with Vag Delivery Charge,7200033,CDM,720,RC,,,,,Outpatient,,,5422,,,,80,,4337.6,percent of total billed charges,,,,85,4608.7,percent of total billed charges,,,77.7,,4212.89,percent of total billed charges,,,95,,5150.9,percent of total billed charges,,,60,,3253.2,percent of total billed charges,,3253.2,5150.9,
L&D with Vag Delivery Charge,7200033,CDM,720,RC,,,,,Inpatient,,,5422,,,,80,,4337.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4212.89,percent of total billed charges,,,95,,5150.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5150.9,
L&D FETAL NON-STRESS TEST,7200034,CDM,720,RC,59025,CPT,,,Outpatient,,,455,,,,80,,364,percent of total billed charges,,,,50,179.89,fee schedule,,,77.7,,353.54,percent of total billed charges,,,95,,432.25,percent of total billed charges,,,60,,273,percent of total billed charges,,273,432.25,
L&D FETAL NON-STRESS TEST,7200034,CDM,720,RC,59025,CPT,,,Inpatient,,,455,,,,80,,364,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,353.54,percent of total billed charges,,,95,,432.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,432.25,
L&D POSTPARTUM CARE ONLY,7200035,CDM,720,RC,,,,,Outpatient,,,540,,,,80,,432,percent of total billed charges,,,,85,459,percent of total billed charges,,,77.7,,419.58,percent of total billed charges,,,95,,513,percent of total billed charges,,,60,,324,percent of total billed charges,,324,513,
L&D POSTPARTUM CARE ONLY,7200035,CDM,720,RC,,,,,Inpatient,,,540,,,,80,,432,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,419.58,percent of total billed charges,,,95,,513,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,513,
L&D VBAC DELIVERY,7200036,CDM,720,RC,,,,,Outpatient,,,5708,,,,80,,4566.4,percent of total billed charges,,,,85,4851.8,percent of total billed charges,,,77.7,,4435.12,percent of total billed charges,,,95,,5422.6,percent of total billed charges,,,60,,3424.8,percent of total billed charges,,3424.8,5422.6,
L&D VBAC DELIVERY,7200036,CDM,720,RC,,,,,Inpatient,,,5708,,,,80,,4566.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4435.12,percent of total billed charges,,,95,,5422.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5422.6,
L&D-Non Vag Delivery or Transfer Out 1ST HR Charge,7200037,CDM,720,RC,,,,,Outpatient,,,800,,,,80,,640,percent of total billed charges,,,,85,680,percent of total billed charges,,,77.7,,621.6,percent of total billed charges,,,95,,760,percent of total billed charges,,,60,,480,percent of total billed charges,,480,760,
L&D-Non Vag Delivery or Transfer Out 1ST HR Charge,7200037,CDM,720,RC,,,,,Inpatient,,,800,,,,80,,640,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,621.6,percent of total billed charges,,,95,,760,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,760,
LABOR PLANNED C-SECTION PER HOUR Charge,7200038,CDM,720,RC,,,,,Outpatient,,,170,,,,80,,136,percent of total billed charges,,,,85,144.5,percent of total billed charges,,,77.7,,132.09,percent of total billed charges,,,95,,161.5,percent of total billed charges,,,60,,102,percent of total billed charges,,102,161.5,
LABOR PLANNED C-SECTION PER HOUR Charge,7200038,CDM,720,RC,,,,,Inpatient,,,170,,,,80,,136,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,132.09,percent of total billed charges,,,95,,161.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,161.5,
L&D- NON VAG DELIVERY or TRANSFER OUT EA  ADDL HR Charge,7200039,CDM,720,RC,,,,,Outpatient,,,150,,,,80,,120,percent of total billed charges,,,,85,127.5,percent of total billed charges,,,77.7,,116.55,percent of total billed charges,,,95,,142.5,percent of total billed charges,,,60,,90,percent of total billed charges,,90,142.5,
L&D- NON VAG DELIVERY or TRANSFER OUT EA  ADDL HR Charge,7200039,CDM,720,RC,,,,,Inpatient,,,150,,,,80,,120,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,116.55,percent of total billed charges,,,95,,142.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,142.5,
Holter Monitor Recording,7300114,CDM,731,RC,93225,CPT,,,Outpatient,,,275,,,,80,,220,percent of total billed charges,,,,50,94.14,fee schedule,,,77.7,,213.68,percent of total billed charges,,,95,,261.25,percent of total billed charges,,,60,,165,percent of total billed charges,,165,261.25,
Holter Monitor Recording,7300114,CDM,731,RC,93225,CPT,,,Inpatient,,,275,,,,80,,220,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,213.68,percent of total billed charges,,,95,,261.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,261.25,
OBSRV ADD'L HR 1ST DAY,7600059,CDM,762,RC,G0378,HCPCS,,,Outpatient,,,30,,,,80,,24,percent of total billed charges,,,,85,25.5,percent of total billed charges,,,77.7,,23.31,percent of total billed charges,,,95,,28.5,percent of total billed charges,,,60,,18,percent of total billed charges,,18,28.5,
OBSRV ADD'L HR 1ST DAY,7600059,CDM,762,RC,G0378,HCPCS,,,Inpatient,,,30,,,,80,,24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,23.31,percent of total billed charges,,,95,,28.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,28.5,
TR 99211 EVAL LEVEL 1 Charge,7600091,CDM,761,RC,99211,CPT,,,Outpatient,,,167,,,,80,,133.6,percent of total billed charges,,,,50,21.25,fee schedule,,,77.7,,129.76,percent of total billed charges,,,95,,158.65,percent of total billed charges,,,60,,100.2,percent of total billed charges,,100.2,158.65,
TR 99211 EVAL LEVEL 1 Charge,7600091,CDM,761,RC,99211,CPT,,,Inpatient,,,167,,,,80,,133.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,129.76,percent of total billed charges,,,95,,158.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,158.65,
OBSRV 1ST HOUR,7601479,CDM,762,RC,G0378,HCPCS,,,Outpatient,,,425,,,,80,,340,percent of total billed charges,,,,85,361.25,percent of total billed charges,,,77.7,,330.23,percent of total billed charges,,,95,,403.75,percent of total billed charges,,,60,,255,percent of total billed charges,,255,403.75,
OBSRV 1ST HOUR,7601479,CDM,762,RC,G0378,HCPCS,,,Inpatient,,,425,,,,80,,340,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,330.23,percent of total billed charges,,,95,,403.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,403.75,
OBSRV 1ST HR W/IV INFUSION,7601529,CDM,762,RC,G0378,HCPCS,,,Outpatient,,,260,,,,80,,208,percent of total billed charges,,,,85,221,percent of total billed charges,,,77.7,,202.02,percent of total billed charges,,,95,,247,percent of total billed charges,,,60,,156,percent of total billed charges,,156,247,
OBSRV 1ST HR W/IV INFUSION,7601529,CDM,762,RC,G0378,HCPCS,,,Inpatient,,,260,,,,80,,208,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,202.02,percent of total billed charges,,,95,,247,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,247,
OBSRV ADD'L HR W/IV INF 1ST DAY,7601537,CDM,762,RC,G0378,HCPCS,,,Outpatient,,,15,,,,80,,12,percent of total billed charges,,,,85,12.75,percent of total billed charges,,,77.7,,11.66,percent of total billed charges,,,95,,14.25,percent of total billed charges,,,60,,9,percent of total billed charges,,9,14.25,
OBSRV ADD'L HR W/IV INF 1ST DAY,7601537,CDM,762,RC,G0378,HCPCS,,,Inpatient,,,15,,,,80,,12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.66,percent of total billed charges,,,95,,14.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,14.25,
TR 36591 BLOOD COLLECT- IMPLANT VENOUS Charge,7602097,CDM,761,RC,36591,CPT,,,Outpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,50,63.34,fee schedule,,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,60,,157.06,percent of total billed charges,,157.06,248.68,
TR 36591 BLOOD COLLECT- IMPLANT VENOUS Charge,7602097,CDM,761,RC,36591,CPT,,,Inpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,248.68,
TR 96360 IV HYDRA. INITIAL 31-90 MIN Charge,7603830,CDM,761,RC,96360,CPT,,,Outpatient,,,339,,,,80,,271.2,percent of total billed charges,,,,50,114.91,fee schedule,,,77.7,,263.4,percent of total billed charges,,,95,,322.05,percent of total billed charges,,,60,,203.4,percent of total billed charges,,203.4,322.05,
TR 96360 IV HYDRA. INITIAL 31-90 MIN Charge,7603830,CDM,761,RC,96360,CPT,,,Inpatient,,,339,,,,80,,271.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,263.4,percent of total billed charges,,,95,,322.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,322.05,
TR 96367 IV INFU THER EA ADD'L HR SEQ NEW Charge,7603897,CDM,761,RC,96367,CPT,,,Outpatient,,,192,,,,80,,153.6,percent of total billed charges,,,,50,66.66,fee schedule,,,77.7,,149.18,percent of total billed charges,,,95,,182.4,percent of total billed charges,,,60,,115.2,percent of total billed charges,,115.2,182.4,
TR 96367 IV INFU THER EA ADD'L HR SEQ NEW Charge,7603897,CDM,761,RC,96367,CPT,,,Inpatient,,,192,,,,80,,153.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,149.18,percent of total billed charges,,,95,,182.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,182.4,
TR 96375 ADD'L PUSH NEW DRUG Charge,7604283,CDM,761,RC,96375,CPT,,,Outpatient,,,79,,,,80,,63.2,percent of total billed charges,,,,50,21.72,fee schedule,,,77.7,,61.38,percent of total billed charges,,,95,,75.05,percent of total billed charges,,,60,,47.4,percent of total billed charges,,47.4,75.05,
TR 96375 ADD'L PUSH NEW DRUG Charge,7604283,CDM,761,RC,96375,CPT,,,Inpatient,,,79,,,,80,,63.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,61.38,percent of total billed charges,,,95,,75.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,75.05,
TR 96376 ADD'L PUSH SAME DRUG Charge,7604788,CDM,761,RC,96376,CPT,,,Outpatient,,,71,,,,80,,56.8,percent of total billed charges,,,,50,21.72,fee schedule,,,77.7,,55.17,percent of total billed charges,,,95,,67.45,percent of total billed charges,,,60,,42.6,percent of total billed charges,,42.6,67.45,
TR 96376 ADD'L PUSH SAME DRUG Charge,7604788,CDM,761,RC,96376,CPT,,,Inpatient,,,71,,,,80,,56.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,55.17,percent of total billed charges,,,95,,67.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,67.45,
TR 96413 Chemo Therapeutic Initial Charge,7605058,CDM,761,RC,96413,CPT,,,Outpatient,,,450,,,,80,,360,percent of total billed charges,,,,50,179.1,fee schedule,,,77.7,,349.65,percent of total billed charges,,,95,,427.5,percent of total billed charges,,,60,,270,percent of total billed charges,,270,427.5,
TR 96413 Chemo Therapeutic Initial Charge,7605058,CDM,761,RC,96413,CPT,,,Inpatient,,,450,,,,80,,360,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,349.65,percent of total billed charges,,,95,,427.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,427.5,
TR 94640 INHALATION TRMT (AEROSOL/NEB) Charge,7605132,CDM,761,RC,94640,CPT,,,Outpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,50,20.89,fee schedule,,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,60,,157.06,percent of total billed charges,,157.06,248.68,
TR 94640 INHALATION TRMT (AEROSOL/NEB) Charge,7605132,CDM,761,RC,94640,CPT,,,Inpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,248.68,
OBSRV ADD'L HR SUBSEQUENT DAY,7605173,CDM,762,RC,G0378,HCPCS,,,Outpatient,,,45,,,,80,,36,percent of total billed charges,,,,85,38.25,percent of total billed charges,,,77.7,,34.97,percent of total billed charges,,,95,,42.75,percent of total billed charges,,,60,,27,percent of total billed charges,,27,42.75,
OBSRV ADD'L HR SUBSEQUENT DAY,7605173,CDM,762,RC,G0378,HCPCS,,,Inpatient,,,45,,,,80,,36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,34.97,percent of total billed charges,,,95,,42.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,42.75,
OBSRV ADD'L HR W/IV INF SUBSEQ DAY Charge,7605181,CDM,762,RC,G0378,HCPCS,,,Outpatient,,,25,,,,80,,20,percent of total billed charges,,,,85,21.25,percent of total billed charges,,,77.7,,19.43,percent of total billed charges,,,95,,23.75,percent of total billed charges,,,60,,15,percent of total billed charges,,15,23.75,
OBSRV ADD'L HR W/IV INF SUBSEQ DAY Charge,7605181,CDM,762,RC,G0378,HCPCS,,,Inpatient,,,25,,,,80,,20,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.43,percent of total billed charges,,,95,,23.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,23.75,
TR 11730 AVULSN NAIL PLATE PART/COMP SIMP Charge,7605587,CDM,761,RC,11730,CPT,,,Outpatient,,,243,,,,80,,194.4,percent of total billed charges,,,,50,108.86,fee schedule,,,77.7,,188.81,percent of total billed charges,,,95,,230.85,percent of total billed charges,,,60,,145.8,percent of total billed charges,,145.8,230.85,
TR 11730 AVULSN NAIL PLATE PART/COMP SIMP Charge,7605587,CDM,761,RC,11730,CPT,,,Inpatient,,,243,,,,80,,194.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,188.81,percent of total billed charges,,,95,,230.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,230.85,
TR 51702 INSERT FOLEY CATHETER SIMPLE,7605629,CDM,761,RC,51702,CPT,,,Outpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,50,72.45,fee schedule,,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,60,,157.06,percent of total billed charges,,157.06,248.68,
TR 51702 INSERT FOLEY CATHETER SIMPLE,7605629,CDM,761,RC,51702,CPT,,,Inpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,248.68,
OBS INHALATION TRMT (AEROSOL/NEB) Charge,7606080,CDM,760,RC,94640,CPT,,,Outpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,50,20.89,fee schedule,,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,60,,157.06,percent of total billed charges,,157.06,248.68,
OBS INHALATION TRMT (AEROSOL/NEB) Charge,7606080,CDM,760,RC,94640,CPT,,,Inpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,248.68,
TR 49083 ABD PARACENTESIS W/IMAGING,7606155,CDM,761,RC,49083,CPT,,,Outpatient,,,1133,,,,80,,906.4,percent of total billed charges,,,,50,347.95,fee schedule,,,77.7,,880.34,percent of total billed charges,,,95,,1076.35,percent of total billed charges,,,60,,679.8,percent of total billed charges,,679.8,1076.35,
TR 49083 ABD PARACENTESIS W/IMAGING,7606155,CDM,761,RC,49083,CPT,,,Inpatient,,,1133,,,,80,,906.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,880.34,percent of total billed charges,,,95,,1076.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1076.35,
TR 51705 CHANGE CYSTOSTOMY TUBE SIMPLE Charge,7606676,CDM,761,RC,51705,CPT,,,Outpatient,,,557,,,,80,,445.6,percent of total billed charges,,,,50,33.84,fee schedule,,,77.7,,432.79,percent of total billed charges,,,95,,529.15,percent of total billed charges,,,60,,334.2,percent of total billed charges,,334.2,529.15,
TR 51705 CHANGE CYSTOSTOMY TUBE SIMPLE Charge,7606676,CDM,761,RC,51705,CPT,,,Inpatient,,,557,,,,80,,445.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,432.79,percent of total billed charges,,,95,,529.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,529.15,
TR 36556 INSERT NT CV CATH 5+ Charge,7606825,CDM,761,RC,36556,CPT,,,Outpatient,,,3400,,,,80,,2720,percent of total billed charges,,,,50,1333.2,fee schedule,,,77.7,,2641.8,percent of total billed charges,,,95,,3230,percent of total billed charges,,,60,,2040,percent of total billed charges,,2040,3230,
TR 36556 INSERT NT CV CATH 5+ Charge,7606825,CDM,761,RC,36556,CPT,,,Inpatient,,,3400,,,,80,,2720,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2641.8,percent of total billed charges,,,95,,3230,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3230,
TR 62273 INJECT EPIDURAL BLOOD/CLOT PATCH Charge,7606858,CDM,761,RC,62273,CPT,,,Outpatient,,,869,,,,80,,695.2,percent of total billed charges,,,,85,738.65,percent of total billed charges,,,77.7,,675.21,percent of total billed charges,,,95,,825.55,percent of total billed charges,,,60,,521.4,percent of total billed charges,,521.4,825.55,
TR 62273 INJECT EPIDURAL BLOOD/CLOT PATCH Charge,7606858,CDM,761,RC,62273,CPT,,,Inpatient,,,869,,,,80,,695.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,675.21,percent of total billed charges,,,95,,825.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,825.55,
TR 54150 CIRCUMCISION W/REGIONL BLOCK Charge,7608391,CDM,761,RC,54150,CPT,,,Outpatient,,,2250,,,,80,,1800,percent of total billed charges,,,,50,1122.14,fee schedule,,,77.7,,1748.25,percent of total billed charges,,,95,,2137.5,percent of total billed charges,,,60,,1350,percent of total billed charges,,1350,2137.5,
TR 54150 CIRCUMCISION W/REGIONL BLOCK Charge,7608391,CDM,761,RC,54150,CPT,,,Inpatient,,,2250,,,,80,,1800,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1748.25,percent of total billed charges,,,95,,2137.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2137.5,
TR 36569 INSERT PICC WO PORT WO IMG 5YR/>,7611403,CDM,761,RC,36569,CPT,,,Outpatient,,,2001,,,,80,,1600.8,percent of total billed charges,,,,85,1700.85,percent of total billed charges,,,77.7,,1554.78,percent of total billed charges,,,95,,1900.95,percent of total billed charges,,,60,,1200.6,percent of total billed charges,,1200.6,1900.95,
TR 36569 INSERT PICC WO PORT WO IMG 5YR/>,7611403,CDM,761,RC,36569,CPT,,,Inpatient,,,2001,,,,80,,1600.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1554.78,percent of total billed charges,,,95,,1900.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1900.95,
TR 36573 INSERT PICC WO PORT W/IMG >5YR,7611411,CDM,761,RC,36573,CPT,,,Outpatient,,,3050,,,,80,,2440,percent of total billed charges,,,,85,2592.5,percent of total billed charges,,,77.7,,2369.85,percent of total billed charges,,,95,,2897.5,percent of total billed charges,,,60,,1830,percent of total billed charges,,1830,2897.5,
TR 36573 INSERT PICC WO PORT W/IMG >5YR,7611411,CDM,761,RC,36573,CPT,,,Inpatient,,,3050,,,,80,,2440,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2369.85,percent of total billed charges,,,95,,2897.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2897.5,
US Carotid Duplex Bilateral,9200023,CDM,921,RC,93880,CPT,,,Outpatient,,,683,,,,80,,546.4,percent of total billed charges,,,,50,240.38,fee schedule,,,77.7,,530.69,percent of total billed charges,,,95,,648.85,percent of total billed charges,,,60,,409.8,percent of total billed charges,,409.8,648.85,
US Carotid Duplex Bilateral,9200023,CDM,921,RC,93880,CPT,,,Inpatient,,,683,,,,80,,546.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,530.69,percent of total billed charges,,,95,,648.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,648.85,
US LE Venous Duplex Left,9200114,CDM,402,RC,93971,CPT,,,Outpatient,,,824,,,,80,,659.2,percent of total billed charges,,,,50,240.38,fee schedule,,,77.7,,640.25,percent of total billed charges,,,95,,782.8,percent of total billed charges,,,60,,494.4,percent of total billed charges,,494.4,782.8,
US LE Venous Duplex Left,9200114,CDM,402,RC,93971,CPT,,,Inpatient,,,824,,,,80,,659.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,640.25,percent of total billed charges,,,95,,782.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,782.8,
US LE Arterial Duplex Bilateral,9200130,CDM,402,RC,93925,CPT,,,Outpatient,,,657,,,,80,,525.6,percent of total billed charges,,,,50,240.38,fee schedule,,,77.7,,510.49,percent of total billed charges,,,95,,624.15,percent of total billed charges,,,60,,394.2,percent of total billed charges,,394.2,624.15,
US LE Arterial Duplex Bilateral,9200130,CDM,402,RC,93925,CPT,,,Inpatient,,,657,,,,80,,525.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,510.49,percent of total billed charges,,,95,,624.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,624.15,
US LE Venous Doppler Bilateral,9200148,CDM,402,RC,93970,CPT,,,Outpatient,,,774,,,,80,,619.2,percent of total billed charges,,,,50,240.38,fee schedule,,,77.7,,601.4,percent of total billed charges,,,95,,735.3,percent of total billed charges,,,60,,464.4,percent of total billed charges,,464.4,735.3,
US LE Venous Duplex Bilateral,9200148,CDM,402,RC,93970,CPT,,,Outpatient,,,774,,,,80,,619.2,percent of total billed charges,,,,50,240.38,fee schedule,,,77.7,,601.4,percent of total billed charges,,,95,,735.3,percent of total billed charges,,,60,,464.4,percent of total billed charges,,464.4,735.3,
US LE Venous Doppler Bilateral,9200148,CDM,402,RC,93970,CPT,,,Inpatient,,,774,,,,80,,619.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,601.4,percent of total billed charges,,,95,,735.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,735.3,
US LE Venous Duplex Bilateral,9200148,CDM,402,RC,93970,CPT,,,Inpatient,,,774,,,,80,,619.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,601.4,percent of total billed charges,,,95,,735.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,735.3,
US Ankle Brachial Index,9200163,CDM,402,RC,93922,CPT,,,Outpatient,,,603,,,,80,,482.4,percent of total billed charges,,,,50,240.38,fee schedule,,,77.7,,468.53,percent of total billed charges,,,95,,572.85,percent of total billed charges,,,60,,361.8,percent of total billed charges,,361.8,572.85,
US Ankle Brachial Index,9200163,CDM,402,RC,93922,CPT,,,Inpatient,,,603,,,,80,,482.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,468.53,percent of total billed charges,,,95,,572.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,572.85,
US LE Arterial Duplex Left,9200189,CDM,402,RC,93926,CPT,,,Outpatient,,,603,,,,80,,482.4,percent of total billed charges,,,,50,240.38,fee schedule,,,77.7,,468.53,percent of total billed charges,,,95,,572.85,percent of total billed charges,,,60,,361.8,percent of total billed charges,,361.8,572.85,
US LE Arterial Duplex Left,9200189,CDM,402,RC,93926,CPT,,,Inpatient,,,603,,,,80,,482.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,468.53,percent of total billed charges,,,95,,572.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,572.85,
CR Phase II 93798,9400011,CDM,943,RC,93798,CPT,,,Outpatient,,,256,,,,80,,204.8,percent of total billed charges,,,,50,65.21,fee schedule,,,77.7,,198.91,percent of total billed charges,,,95,,243.2,percent of total billed charges,,,60,,153.6,percent of total billed charges,,153.6,243.2,
CR Phase II 93798,9400011,CDM,943,RC,93798,CPT,,,Inpatient,,,256,,,,80,,204.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,198.91,percent of total billed charges,,,95,,243.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,243.2,
36415 VENIPUNCTURE,30036415,CDM,300,RC,36415,CPT,,,Outpatient,,,32,,,,80,,25.6,percent of total billed charges,,,,50,6.03,fee schedule,,,77.7,,24.86,percent of total billed charges,,,95,,30.4,percent of total billed charges,,,60,,19.2,percent of total billed charges,,19.2,30.4,
COLLECTION: Venous Draw,30036415,CDM,300,RC,36415,CPT,,,Outpatient,,,32,,,,80,,25.6,percent of total billed charges,,,,50,6.03,fee schedule,,,77.7,,24.86,percent of total billed charges,,,95,,30.4,percent of total billed charges,,,60,,19.2,percent of total billed charges,,19.2,30.4,
36415 VENIPUNCTURE,30036415,CDM,300,RC,36415,CPT,,,Inpatient,,,32,,,,80,,25.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,24.86,percent of total billed charges,,,95,,30.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,30.4,
COLLECTION: Venous Draw,30036415,CDM,300,RC,36415,CPT,,,Inpatient,,,32,,,,80,,25.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,24.86,percent of total billed charges,,,95,,30.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,30.4,
36416 CAPILLARY CHARGE,30036416,CDM,300,RC,36416,CPT,,,Outpatient,,,25,,,,80,,20,percent of total billed charges,,,,50,2.21,fee schedule,,,77.7,,19.43,percent of total billed charges,,,95,,23.75,percent of total billed charges,,,60,,15,percent of total billed charges,,15,23.75,
COLLECTION: Capillary,30036416,CDM,300,RC,36416,CPT,,,Outpatient,,,25,,,,80,,20,percent of total billed charges,,,,50,2.21,fee schedule,,,77.7,,19.43,percent of total billed charges,,,95,,23.75,percent of total billed charges,,,60,,15,percent of total billed charges,,15,23.75,
36416 CAPILLARY CHARGE,30036416,CDM,300,RC,36416,CPT,,,Inpatient,,,25,,,,80,,20,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.43,percent of total billed charges,,,95,,23.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,23.75,
COLLECTION: Capillary,30036416,CDM,300,RC,36416,CPT,,,Inpatient,,,25,,,,80,,20,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.43,percent of total billed charges,,,95,,23.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,23.75,
COLLECTION: Arterial Draw,30036600,CDM,300,RC,36600,CPT,,,Outpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,50,33.84,fee schedule,,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,60,,157.06,percent of total billed charges,,157.06,248.68,
COLLECTION: Arterial Draw,30036600,CDM,300,RC,36600,CPT,,,Inpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,248.68,
Lipid Panel,30080061,CDM,300,RC,80061,CPT,,,Outpatient,,,192,,,,80,,153.6,percent of total billed charges,,,,50,21.59,fee schedule,,,77.7,,149.18,percent of total billed charges,,,95,,182.4,percent of total billed charges,,,60,,115.2,percent of total billed charges,,115.2,182.4,
Lipid Panel,30080061,CDM,300,RC,80061,CPT,,,Outpatient,,,192,,,,80,,153.6,percent of total billed charges,,,,50,21.59,fee schedule,,,77.7,,149.18,percent of total billed charges,,,95,,182.4,percent of total billed charges,,,60,,115.2,percent of total billed charges,,115.2,182.4,
Lipid Panel,30080061,CDM,300,RC,80061,CPT,,,Inpatient,,,192,,,,80,,153.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,149.18,percent of total billed charges,,,95,,182.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,182.4,
Lipid Panel,30080061,CDM,300,RC,80061,CPT,,,Inpatient,,,192,,,,80,,153.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,149.18,percent of total billed charges,,,95,,182.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,182.4,
Acetaminophen Lvl,30080143,CDM,300,RC,80143,CPT,,,Outpatient,,,110,,,,80,,88,percent of total billed charges,,,,50,14.55,fee schedule,,,77.7,,85.47,percent of total billed charges,,,95,,104.5,percent of total billed charges,,,60,,66,percent of total billed charges,,66,104.5,
Acetaminophen Lvl,30080143,CDM,300,RC,80143,CPT,,,Inpatient,,,110,,,,80,,88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,85.47,percent of total billed charges,,,95,,104.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,104.5,
Salicylate Level,30080179,CDM,300,RC,80179,CPT,,,Outpatient,,,72,,,,80,,57.6,percent of total billed charges,,,,50,14.55,fee schedule,,,77.7,,55.94,percent of total billed charges,,,95,,68.4,percent of total billed charges,,,60,,43.2,percent of total billed charges,,43.2,68.4,
Salicylate Level,30080179,CDM,300,RC,80179,CPT,,,Inpatient,,,72,,,,80,,57.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,55.94,percent of total billed charges,,,95,,68.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,68.4,
Vanco Level,30080202,CDM,300,RC,80202,CPT,,,Outpatient,,,154,,,,80,,123.2,percent of total billed charges,,,,50,29.48,fee schedule,,,77.7,,119.66,percent of total billed charges,,,95,,146.3,percent of total billed charges,,,60,,92.4,percent of total billed charges,,92.4,146.3,
Vancomycin Level Peak,30080202,CDM,300,RC,80202,CPT,,,Outpatient,,,154,,,,80,,123.2,percent of total billed charges,,,,50,29.48,fee schedule,,,77.7,,119.66,percent of total billed charges,,,95,,146.3,percent of total billed charges,,,60,,92.4,percent of total billed charges,,92.4,146.3,
Vancomycin Level Trough,30080202,CDM,300,RC,80202,CPT,,,Outpatient,,,154,,,,80,,123.2,percent of total billed charges,,,,50,29.48,fee schedule,,,77.7,,119.66,percent of total billed charges,,,95,,146.3,percent of total billed charges,,,60,,92.4,percent of total billed charges,,92.4,146.3,
Vanco Level,30080202,CDM,300,RC,80202,CPT,,,Inpatient,,,154,,,,80,,123.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,119.66,percent of total billed charges,,,95,,146.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,146.3,
Vancomycin Level Peak,30080202,CDM,300,RC,80202,CPT,,,Inpatient,,,154,,,,80,,123.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,119.66,percent of total billed charges,,,95,,146.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,146.3,
Vancomycin Level Trough,30080202,CDM,300,RC,80202,CPT,,,Inpatient,,,154,,,,80,,123.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,119.66,percent of total billed charges,,,95,,146.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,146.3,
U Drug Scrn w QC,30080305,CDM,300,RC,80305,CPT,,,Outpatient,,,373,,,,80,,298.4,percent of total billed charges,,,,50,14.08,fee schedule,,,77.7,,289.82,percent of total billed charges,,,95,,354.35,percent of total billed charges,,,60,,223.8,percent of total billed charges,,223.8,354.35,
U Drug Scrn w QC,30080305,CDM,300,RC,80305,CPT,,,Inpatient,,,373,,,,80,,298.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,289.82,percent of total billed charges,,,95,,354.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,354.35,
Ethanol,30080320,CDM,300,RC,80320,CPT,,,Outpatient,,,161,,,,80,,128.8,percent of total billed charges,,,,50,30.32,fee schedule,,,77.7,,125.1,percent of total billed charges,,,95,,152.95,percent of total billed charges,,,60,,96.6,percent of total billed charges,,96.6,152.95,
Ethanol,30080320,CDM,300,RC,80320,CPT,,,Inpatient,,,161,,,,80,,128.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,125.1,percent of total billed charges,,,95,,152.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,152.95,
81001 UA AUTOMATED W/ MICRO,30081001,CDM,300,RC,81001,CPT,,,Outpatient,,,55,,,,80,,44,percent of total billed charges,,,,50,4.86,fee schedule,,,77.7,,42.74,percent of total billed charges,,,95,,52.25,percent of total billed charges,,,60,,33,percent of total billed charges,,33,52.25,
81001 UA AUTOMATED W/ MICRO,30081001,CDM,300,RC,81001,CPT,,,Inpatient,,,55,,,,80,,44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,42.74,percent of total billed charges,,,95,,52.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,52.25,
Albumin Level,30082040,CDM,300,RC,82040,CPT,,,Outpatient,,,64,,,,80,,51.2,percent of total billed charges,,,,50,5.32,fee schedule,,,77.7,,49.73,percent of total billed charges,,,95,,60.8,percent of total billed charges,,,60,,38.4,percent of total billed charges,,38.4,60.8,
Albumin Level,30082040,CDM,300,RC,82040,CPT,,,Inpatient,,,64,,,,80,,51.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,49.73,percent of total billed charges,,,95,,60.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,60.8,
U Microalb/Creat,30082043,CDM,300,RC,82043,CPT,,,Outpatient,,,73,,,,80,,58.4,percent of total billed charges,,,,50,12.41,fee schedule,,,77.7,,56.72,percent of total billed charges,,,95,,69.35,percent of total billed charges,,,60,,43.8,percent of total billed charges,,43.8,69.35,
U Microalb/Creat,30082043,CDM,300,RC,82043,CPT,,,Inpatient,,,73,,,,80,,58.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,56.72,percent of total billed charges,,,95,,69.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,69.35,
Bilirubin Total and Direct,30082247,CDM,300,RC,82247,CPT,,,Outpatient,,,64,,,,80,,51.2,percent of total billed charges,,,,50,10.65,fee schedule,,,77.7,,49.73,percent of total billed charges,,,95,,60.8,percent of total billed charges,,,60,,38.4,percent of total billed charges,,38.4,60.8,
Bilirubin Total and Direct,30082247,CDM,300,RC,82247,CPT,,,Inpatient,,,64,,,,80,,51.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,49.73,percent of total billed charges,,,95,,60.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,60.8,
82248 BILIRUBIN DIRECT,30082248,CDM,300,RC,82248,CPT,,,Outpatient,,,64,,,,80,,51.2,percent of total billed charges,,,,50,10.09,fee schedule,,,77.7,,49.73,percent of total billed charges,,,95,,60.8,percent of total billed charges,,,60,,38.4,percent of total billed charges,,38.4,60.8,
82248 BILIRUBIN DIRECT,30082248,CDM,300,RC,82248,CPT,,,Inpatient,,,64,,,,80,,51.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,49.73,percent of total billed charges,,,95,,60.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,60.8,
Fecal Occult Blood Diagnostic - IA,30082274,CDM,300,RC,82274,CPT,,,Outpatient,,,36,,,,80,,28.8,percent of total billed charges,,,,50,17.07,fee schedule,,,77.7,,27.97,percent of total billed charges,,,95,,34.2,percent of total billed charges,,,60,,21.6,percent of total billed charges,,21.6,34.2,
Fecal Occult Blood Diagnostic - IA,30082274,CDM,300,RC,82274,CPT,,,Inpatient,,,36,,,,80,,28.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,27.97,percent of total billed charges,,,95,,34.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,34.2,
Chloride Level Urine,30082436,CDM,300,RC,82436,CPT,,,Outpatient,,,58,,,,80,,46.4,percent of total billed charges,,,,50,10.41,fee schedule,,,77.7,,45.07,percent of total billed charges,,,95,,55.1,percent of total billed charges,,,60,,34.8,percent of total billed charges,,34.8,55.1,
Chloride Level Urine,30082436,CDM,300,RC,82436,CPT,,,Inpatient,,,58,,,,80,,46.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,45.07,percent of total billed charges,,,95,,55.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,55.1,
82565 Creatinine,30082565,CDM,300,RC,82565,CPT,,,Outpatient,,,60,,,,80,,48,percent of total billed charges,,,,50,5.5,fee schedule,,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,60,,36,percent of total billed charges,,36,57,
Creatinine with eGFR,30082565,CDM,300,RC,82565,CPT,,,Outpatient,,,60,,,,80,,48,percent of total billed charges,,,,50,5.5,fee schedule,,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,60,,36,percent of total billed charges,,36,57,
82565 Creatinine,30082565,CDM,300,RC,82565,CPT,,,Inpatient,,,60,,,,80,,48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,57,
Creatinine with eGFR,30082565,CDM,300,RC,82565,CPT,,,Inpatient,,,60,,,,80,,48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,57,
U Prot/Creat,30082570,CDM,300,RC,82570,CPT,,,Outpatient,,,73,,,,80,,58.4,percent of total billed charges,,,,50,10.77,fee schedule,,,77.7,,56.72,percent of total billed charges,,,95,,69.35,percent of total billed charges,,,60,,43.8,percent of total billed charges,,43.8,69.35,
U Prot/Creat,30082570,CDM,300,RC,82570,CPT,,,Inpatient,,,73,,,,80,,58.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,56.72,percent of total billed charges,,,95,,69.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,69.35,
Vitamin B12 and Folate LC,30082607,CDM,300,RC,82607,CPT,,,Outpatient,,,150,,,,80,,120,percent of total billed charges,,,,50,28.71,fee schedule,,,77.7,,116.55,percent of total billed charges,,,95,,142.5,percent of total billed charges,,,60,,90,percent of total billed charges,,90,142.5,
Vitamin B12 and Folate LC,30082607,CDM,300,RC,82607,CPT,,,Inpatient,,,150,,,,80,,120,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,116.55,percent of total billed charges,,,95,,142.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,142.5,
Ferritin,30082728,CDM,300,RC,82728,CPT,,,Outpatient,,,148,,,,80,,118.4,percent of total billed charges,,,,50,26.62,fee schedule,,,77.7,,115,percent of total billed charges,,,95,,140.6,percent of total billed charges,,,60,,88.8,percent of total billed charges,,88.8,140.6,
Ferritin,30082728,CDM,300,RC,82728,CPT,,,Inpatient,,,148,,,,80,,118.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,115,percent of total billed charges,,,95,,140.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,140.6,
82746 FOLATE,30082746,CDM,300,RC,82746,CPT,,,Outpatient,,,169,,,,80,,135.2,percent of total billed charges,,,,50,30.91,fee schedule,,,77.7,,131.31,percent of total billed charges,,,95,,160.55,percent of total billed charges,,,60,,101.4,percent of total billed charges,,101.4,160.55,
82746 FOLATE,30082746,CDM,300,RC,82746,CPT,,,Inpatient,,,169,,,,80,,135.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,131.31,percent of total billed charges,,,95,,160.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,160.55,
Blood Gas Venous - Cord Blood,30082805,CDM,300,RC,82805,CPT,,,Outpatient,,,223,,,,80,,178.4,percent of total billed charges,,,,50,58.97,fee schedule,,,77.7,,173.27,percent of total billed charges,,,95,,211.85,percent of total billed charges,,,60,,133.8,percent of total billed charges,,133.8,211.85,
Blood Gas Venous - Cord Blood,30082805,CDM,300,RC,82805,CPT,,,Inpatient,,,223,,,,80,,178.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,173.27,percent of total billed charges,,,95,,211.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,211.85,
.Gluc 1 Hr - Gest(1 hr GTT),30082950,CDM,300,RC,82950,CPT,,,Outpatient,,,57,,,,80,,45.6,percent of total billed charges,,,,50,10.04,fee schedule,,,77.7,,44.29,percent of total billed charges,,,95,,54.15,percent of total billed charges,,,60,,34.2,percent of total billed charges,,34.2,54.15,
GTT 1 Hr - Gestational,30082950,CDM,300,RC,82950,CPT,,,Outpatient,,,57,,,,80,,45.6,percent of total billed charges,,,,50,10.04,fee schedule,,,77.7,,44.29,percent of total billed charges,,,95,,54.15,percent of total billed charges,,,60,,34.2,percent of total billed charges,,34.2,54.15,
Glucose 2 Hour Postprandial,30082950,CDM,300,RC,82950,CPT,,,Outpatient,,,57,,,,80,,45.6,percent of total billed charges,,,,50,10.04,fee schedule,,,77.7,,44.29,percent of total billed charges,,,95,,54.15,percent of total billed charges,,,60,,34.2,percent of total billed charges,,34.2,54.15,
.Gluc 1 Hr - Gest(1 hr GTT),30082950,CDM,300,RC,82950,CPT,,,Inpatient,,,57,,,,80,,45.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,44.29,percent of total billed charges,,,95,,54.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,54.15,
GTT 1 Hr - Gestational,30082950,CDM,300,RC,82950,CPT,,,Inpatient,,,57,,,,80,,45.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,44.29,percent of total billed charges,,,95,,54.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,54.15,
Glucose 2 Hour Postprandial,30082950,CDM,300,RC,82950,CPT,,,Inpatient,,,57,,,,80,,45.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,44.29,percent of total billed charges,,,95,,54.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,54.15,
.Gluc Fasting,30082951,CDM,300,RC,82951,CPT,,,Outpatient,,,122,,,,80,,97.6,percent of total billed charges,,,,50,24.36,fee schedule,,,77.7,,94.79,percent of total billed charges,,,95,,115.9,percent of total billed charges,,,60,,73.2,percent of total billed charges,,73.2,115.9,
.Gluc Fasting - Gest(2 hr GTT),30082951,CDM,300,RC,82951,CPT,,,Outpatient,,,122,,,,80,,97.6,percent of total billed charges,,,,50,24.36,fee schedule,,,77.7,,94.79,percent of total billed charges,,,95,,115.9,percent of total billed charges,,,60,,73.2,percent of total billed charges,,73.2,115.9,
.Gluc Fasting - Gest(3 hr GTT),30082951,CDM,300,RC,82951,CPT,,,Outpatient,,,122,,,,80,,97.6,percent of total billed charges,,,,50,24.36,fee schedule,,,77.7,,94.79,percent of total billed charges,,,95,,115.9,percent of total billed charges,,,60,,73.2,percent of total billed charges,,73.2,115.9,
.Gluc Fasting,30082951,CDM,300,RC,82951,CPT,,,Inpatient,,,122,,,,80,,97.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,94.79,percent of total billed charges,,,95,,115.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,115.9,
.Gluc Fasting - Gest(2 hr GTT),30082951,CDM,300,RC,82951,CPT,,,Inpatient,,,122,,,,80,,97.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,94.79,percent of total billed charges,,,95,,115.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,115.9,
.Gluc Fasting - Gest(3 hr GTT),30082951,CDM,300,RC,82951,CPT,,,Inpatient,,,122,,,,80,,97.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,94.79,percent of total billed charges,,,95,,115.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,115.9,
.Gluc 3 Hr - Gest(3 hr GTT),30082952,CDM,300,RC,82952,CPT,,,Outpatient,,,44,,,,80,,35.2,percent of total billed charges,,,,50,7.29,fee schedule,,,77.7,,34.19,percent of total billed charges,,,95,,41.8,percent of total billed charges,,,60,,26.4,percent of total billed charges,,26.4,41.8,
.Gluc 3 Hr - Gest(3 hr GTT),30082952,CDM,300,RC,82952,CPT,,,Inpatient,,,44,,,,80,,35.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,34.19,percent of total billed charges,,,95,,41.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,41.8,
Gamma Glutamyl Transferase,30082977,CDM,300,RC,82977,CPT,,,Outpatient,,,107,,,,80,,85.6,percent of total billed charges,,,,50,7.73,fee schedule,,,77.7,,83.14,percent of total billed charges,,,95,,101.65,percent of total billed charges,,,60,,64.2,percent of total billed charges,,64.2,101.65,
Gamma Glutamyl Transferase,30082977,CDM,300,RC,82977,CPT,,,Inpatient,,,107,,,,80,,85.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,83.14,percent of total billed charges,,,95,,101.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,101.65,
Transferrin / TIBC,30083550,CDM,300,RC,83550,CPT,,,Outpatient,,,75,,,,80,,60,percent of total billed charges,,,,50,20.62,fee schedule,,,77.7,,58.28,percent of total billed charges,,,95,,71.25,percent of total billed charges,,,60,,45,percent of total billed charges,,45,71.25,
Transferrin / TIBC,30083550,CDM,300,RC,83550,CPT,,,Inpatient,,,75,,,,80,,60,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,58.28,percent of total billed charges,,,95,,71.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,71.25,
"Lead, Blood (Pediatric)",30083655,CDM,300,RC,83655,CPT,,,Outpatient,,,63,,,,80,,50.4,percent of total billed charges,,,,50,12.18,fee schedule,,,77.7,,48.95,percent of total billed charges,,,95,,59.85,percent of total billed charges,,,60,,37.8,percent of total billed charges,,37.8,59.85,
"Lead, Blood (Pediatric)",30083655,CDM,300,RC,83655,CPT,,,Inpatient,,,63,,,,80,,50.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,48.95,percent of total billed charges,,,95,,59.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,59.85,
Alkaline Phosphatase,30084075,CDM,300,RC,84075,CPT,,,Outpatient,,,57,,,,80,,45.6,percent of total billed charges,,,,50,5.56,fee schedule,,,77.7,,44.29,percent of total billed charges,,,95,,54.15,percent of total billed charges,,,60,,34.2,percent of total billed charges,,34.2,54.15,
Alkaline Phosphatase,30084075,CDM,300,RC,84075,CPT,,,Inpatient,,,57,,,,80,,45.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,44.29,percent of total billed charges,,,95,,54.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,54.15,
Rapid Rupture of Membrane,30084112,CDM,300,RC,84112,CPT,,,Outpatient,,,210,,,,80,,168,percent of total billed charges,,,,50,62.06,fee schedule,,,77.7,,163.17,percent of total billed charges,,,95,,199.5,percent of total billed charges,,,60,,126,percent of total billed charges,,126,199.5,
Rapid Rupture of Membrane,30084112,CDM,300,RC,84112,CPT,,,Inpatient,,,210,,,,80,,168,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,163.17,percent of total billed charges,,,95,,199.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,199.5,
Potassium Level Urine,30084133,CDM,300,RC,84133,CPT,,,Outpatient,,,58,,,,80,,46.4,percent of total billed charges,,,,50,9.98,fee schedule,,,77.7,,45.07,percent of total billed charges,,,95,,55.1,percent of total billed charges,,,60,,34.8,percent of total billed charges,,34.8,55.1,
Potassium Level Urine,30084133,CDM,300,RC,84133,CPT,,,Inpatient,,,58,,,,80,,46.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,45.07,percent of total billed charges,,,95,,55.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,55.1,
Procalcitonin,30084145,CDM,300,RC,84145,CPT,,,Outpatient,,,168,,,,80,,134.4,percent of total billed charges,,,,50,45.97,fee schedule,,,77.7,,130.54,percent of total billed charges,,,95,,159.6,percent of total billed charges,,,60,,100.8,percent of total billed charges,,100.8,159.6,
Procalcitonin,30084145,CDM,300,RC,84145,CPT,,,Inpatient,,,168,,,,80,,134.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,130.54,percent of total billed charges,,,95,,159.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,159.6,
Prostate Specific Antigen Screen,30084152,CDM,300,RC,G0103,HCPCS,,,Outpatient,,,174,,,,80,,139.2,percent of total billed charges,,,,50,34.99,fee schedule,,,77.7,,135.2,percent of total billed charges,,,95,,165.3,percent of total billed charges,,,60,,104.4,percent of total billed charges,,34.99,165.3,
Prostate Specific Antigen Screen,30084152,CDM,300,RC,G0103,HCPCS,,,Inpatient,,,174,,,,80,,139.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,135.2,percent of total billed charges,,,95,,165.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,165.3,
Sodium Level Urine,30084300,CDM,300,RC,84300,CPT,,,Outpatient,,,57,,,,80,,45.6,percent of total billed charges,,,,50,9.77,fee schedule,,,77.7,,44.29,percent of total billed charges,,,95,,54.15,percent of total billed charges,,,60,,34.2,percent of total billed charges,,34.2,54.15,
Sodium Level Urine,30084300,CDM,300,RC,84300,CPT,,,Inpatient,,,57,,,,80,,45.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,44.29,percent of total billed charges,,,95,,54.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,54.15,
TSH w/ Reflex to Free T4,30084443,CDM,300,RC,84443,CPT,,,Outpatient,,,145,,,,80,,116,percent of total billed charges,,,,50,21.99,fee schedule,,,77.7,,112.67,percent of total billed charges,,,95,,137.75,percent of total billed charges,,,60,,87,percent of total billed charges,,87,137.75,
TSH w/ Reflex to Free T4,30084443,CDM,300,RC,84443,CPT,,,Inpatient,,,145,,,,80,,116,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,112.67,percent of total billed charges,,,95,,137.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,137.75,
Transferrin,30084466,CDM,300,RC,84466,CPT,,,Outpatient,,,166,,,,80,,132.8,percent of total billed charges,,,,50,38.97,fee schedule,,,77.7,,128.98,percent of total billed charges,,,95,,157.7,percent of total billed charges,,,60,,99.6,percent of total billed charges,,99.6,157.7,
Transferrin,30084466,CDM,300,RC,84466,CPT,,,Inpatient,,,166,,,,80,,132.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,128.98,percent of total billed charges,,,95,,157.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,157.7,
High Sensitivity Troponin-I,30084484,CDM,300,RC,84484,CPT,,,Outpatient,,,185,,,,80,,148,percent of total billed charges,,,,50,34.3,fee schedule,,,77.7,,143.75,percent of total billed charges,,,95,,175.75,percent of total billed charges,,,60,,111,percent of total billed charges,,111,175.75,
High Sensitivity Troponin-I,30084484,CDM,300,RC,84484,CPT,,,Inpatient,,,185,,,,80,,148,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,143.75,percent of total billed charges,,,95,,175.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,175.75,
BUN Creatinine Ratio w/ eGFR,30084520,CDM,300,RC,84520,CPT,,,Outpatient,,,60,,,,80,,48,percent of total billed charges,,,,50,4.24,fee schedule,,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,60,,36,percent of total billed charges,,36,57,
BUN Creatinine Ratio w/ eGFR,30084520,CDM,300,RC,84520,CPT,,,Inpatient,,,60,,,,80,,48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,57,
Rapid Pregnancy Test,30084703,CDM,300,RC,84703,CPT,,,Outpatient,,,90,,,,80,,72,percent of total billed charges,,,,50,17.16,fee schedule,,,77.7,,69.93,percent of total billed charges,,,95,,85.5,percent of total billed charges,,,60,,54,percent of total billed charges,,54,85.5,
Rapid Pregnancy Test,30084703,CDM,300,RC,84703,CPT,,,Inpatient,,,90,,,,80,,72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,69.93,percent of total billed charges,,,95,,85.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,85.5,
85025 BLOOD COUNT COMPLETE AUTO&AUTO DIFRNTL WBC,30085025,CDM,300,RC,85025,CPT,,,Outpatient,,,48,,,,80,,38.4,percent of total billed charges,,,,50,6.68,fee schedule,,,77.7,,37.3,percent of total billed charges,,,95,,45.6,percent of total billed charges,,,60,,28.8,percent of total billed charges,,28.8,45.6,
Manual Differential? -> No,30085025,CDM,300,RC,85025,CPT,,,Outpatient,,,48,,,,80,,38.4,percent of total billed charges,,,,50,6.68,fee schedule,,,77.7,,37.3,percent of total billed charges,,,95,,45.6,percent of total billed charges,,,60,,28.8,percent of total billed charges,,28.8,45.6,
Manual Differential? -> No,30085025,CDM,300,RC,85025,CPT,,,Outpatient,,,48,,,,80,,38.4,percent of total billed charges,,,,50,6.68,fee schedule,,,77.7,,37.3,percent of total billed charges,,,95,,45.6,percent of total billed charges,,,60,,28.8,percent of total billed charges,,28.8,45.6,
85025 BLOOD COUNT COMPLETE AUTO&AUTO DIFRNTL WBC,30085025,CDM,300,RC,85025,CPT,,,Inpatient,,,48,,,,80,,38.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,37.3,percent of total billed charges,,,95,,45.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,45.6,
Manual Differential? -> No,30085025,CDM,300,RC,85025,CPT,,,Inpatient,,,48,,,,80,,38.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,37.3,percent of total billed charges,,,95,,45.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,45.6,
Manual Differential? -> No,30085025,CDM,300,RC,85025,CPT,,,Inpatient,,,48,,,,80,,38.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,37.3,percent of total billed charges,,,95,,45.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,45.6,
Complete Blood Count with Manual Differential,30085027,CDM,300,RC,85027,CPT,,,Outpatient,,,39,,,,80,,31.2,percent of total billed charges,,,,50,6.95,fee schedule,,,77.7,,30.3,percent of total billed charges,,,95,,37.05,percent of total billed charges,,,60,,23.4,percent of total billed charges,,23.4,37.05,
Manual Differential? -> Yes,30085027,CDM,300,RC,85027,CPT,,,Outpatient,,,39,,,,80,,31.2,percent of total billed charges,,,,50,6.95,fee schedule,,,77.7,,30.3,percent of total billed charges,,,95,,37.05,percent of total billed charges,,,60,,23.4,percent of total billed charges,,23.4,37.05,
Manual Differential? -> Yes,30085027,CDM,300,RC,85027,CPT,,,Outpatient,,,39,,,,80,,31.2,percent of total billed charges,,,,50,6.95,fee schedule,,,77.7,,30.3,percent of total billed charges,,,95,,37.05,percent of total billed charges,,,60,,23.4,percent of total billed charges,,23.4,37.05,
Complete Blood Count with Manual Differential,30085027,CDM,300,RC,85027,CPT,,,Inpatient,,,39,,,,80,,31.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,30.3,percent of total billed charges,,,95,,37.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,37.05,
Manual Differential? -> Yes,30085027,CDM,300,RC,85027,CPT,,,Inpatient,,,39,,,,80,,31.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,30.3,percent of total billed charges,,,95,,37.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,37.05,
Manual Differential? -> Yes,30085027,CDM,300,RC,85027,CPT,,,Inpatient,,,39,,,,80,,31.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,30.3,percent of total billed charges,,,95,,37.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,37.05,
Reticulocyte,30085045,CDM,300,RC,85045,CPT,,,Outpatient,,,44,,,,80,,35.2,percent of total billed charges,,,,50,39.68,fee schedule,,,77.7,,34.19,percent of total billed charges,,,95,,41.8,percent of total billed charges,,,60,,26.4,percent of total billed charges,,26.4,41.8,
Reticulocyte,30085045,CDM,300,RC,85045,CPT,,,Inpatient,,,44,,,,80,,35.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,34.19,percent of total billed charges,,,95,,41.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,41.8,
Platelet Count,30085049,CDM,300,RC,85049,CPT,,,Outpatient,,,47,,,,80,,37.6,percent of total billed charges,,,,50,7.59,fee schedule,,,77.7,,36.52,percent of total billed charges,,,95,,44.65,percent of total billed charges,,,60,,28.2,percent of total billed charges,,28.2,44.65,
Platelet Count,30085049,CDM,300,RC,85049,CPT,,,Inpatient,,,47,,,,80,,37.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,36.52,percent of total billed charges,,,95,,44.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,44.65,
Rapid Mono Screen,30086308,CDM,300,RC,86308,CPT,,,Outpatient,,,62,,,,80,,49.6,percent of total billed charges,,,,50,9.75,fee schedule,,,77.7,,48.17,percent of total billed charges,,,95,,58.9,percent of total billed charges,,,60,,37.2,percent of total billed charges,,37.2,58.9,
Rapid Mono Screen,30086308,CDM,300,RC,86308,CPT,,,Inpatient,,,62,,,,80,,49.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,48.17,percent of total billed charges,,,95,,58.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,58.9,
86850 Antibody Screen,30086850,CDM,300,RC,86850,CPT,,,Outpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,50,45.64,fee schedule,,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,60,,157.06,percent of total billed charges,,157.06,248.68,
Antibody Screen GL,30086850,CDM,300,RC,86850,CPT,,,Outpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,50,45.64,fee schedule,,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,60,,157.06,percent of total billed charges,,157.06,248.68,
86850 Antibody Screen,30086850,CDM,300,RC,86850,CPT,,,Inpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,248.68,
Antibody Screen GL,30086850,CDM,300,RC,86850,CPT,,,Inpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,248.68,
DAT GL,30086880,CDM,300,RC,86880,CPT,,,Outpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,50,11.62,fee schedule,,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,60,,157.06,percent of total billed charges,,157.06,248.68,
DAT GL,30086880,CDM,300,RC,86880,CPT,,,Inpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,248.68,
Cord Blood ABO/Rh - GL,30086900,CDM,300,RC,86900,CPT,,,Outpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,50,105.38,fee schedule,,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,60,,157.06,percent of total billed charges,,157.06,248.68,
Cord Blood DAT - GL,30086900,CDM,300,RC,86900,CPT,,,Outpatient,,,20.54,,,,80,,16.43,percent of total billed charges,,,,50,105.38,fee schedule,,,77.7,,15.96,percent of total billed charges,,,95,,19.51,percent of total billed charges,,,60,,12.32,percent of total billed charges,,12.32,19.51,
Rhogam Workup GL,30086900,CDM,300,RC,86900,CPT,,,Outpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,50,105.38,fee schedule,,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,60,,157.06,percent of total billed charges,,157.06,248.68,
Type and Cross GL,30086900,CDM,300,RC,86900,CPT,,,Outpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,50,105.38,fee schedule,,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,60,,157.06,percent of total billed charges,,157.06,248.68,
Type and Hold GL,30086900,CDM,300,RC,86900,CPT,,,Outpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,50,105.38,fee schedule,,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,60,,157.06,percent of total billed charges,,157.06,248.68,
Type and Screen GL,30086900,CDM,300,RC,86900,CPT,,,Outpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,50,105.38,fee schedule,,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,60,,157.06,percent of total billed charges,,157.06,248.68,
Cord Blood ABO/Rh - GL,30086900,CDM,300,RC,86900,CPT,,,Inpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,248.68,
Cord Blood DAT - GL,30086900,CDM,300,RC,86900,CPT,,,Inpatient,,,20.54,,,,80,,16.43,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,15.96,percent of total billed charges,,,95,,19.51,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,19.51,
Rhogam Workup GL,30086900,CDM,300,RC,86900,CPT,,,Inpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,248.68,
Type and Cross GL,30086900,CDM,300,RC,86900,CPT,,,Inpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,248.68,
Type and Hold GL,30086900,CDM,300,RC,86900,CPT,,,Inpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,248.68,
Type and Screen GL,30086900,CDM,300,RC,86900,CPT,,,Inpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,248.68,
86901 Rh,30086901,CDM,300,RC,86901,CPT,,,Outpatient,,,64,,,,80,,51.2,percent of total billed charges,,,,50,30.82,fee schedule,,,77.7,,49.73,percent of total billed charges,,,95,,60.8,percent of total billed charges,,,60,,38.4,percent of total billed charges,,38.4,60.8,
86901 Rh,30086901,CDM,300,RC,86901,CPT,,,Inpatient,,,64,,,,80,,51.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,49.73,percent of total billed charges,,,95,,60.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,60.8,
86920 Crossmatch,30086920,CDM,300,RC,86920,CPT,,,Outpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,50,23.17,fee schedule,,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,60,,157.06,percent of total billed charges,,157.06,248.68,
86920 Crossmatch,30086920,CDM,300,RC,86920,CPT,,,Inpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,248.68,
86922 Crossmatch Antiglobulin,30086922,CDM,300,RC,86922,CPT,,,Outpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,50,21.02,fee schedule,,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,60,,157.06,percent of total billed charges,,157.06,248.68,
86922 Crossmatch Antiglobulin,30086922,CDM,300,RC,86922,CPT,,,Inpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,248.68,
MRSA Screen,30087081,CDM,300,RC,87081,CPT,,,Outpatient,,,64,,,,80,,51.2,percent of total billed charges,,,,50,11.98,fee schedule,,,77.7,,49.73,percent of total billed charges,,,95,,60.8,percent of total billed charges,,,60,,38.4,percent of total billed charges,,38.4,60.8,
MRSA Screen,30087081,CDM,300,RC,87081,CPT,,,Inpatient,,,64,,,,80,,51.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,49.73,percent of total billed charges,,,95,,60.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,60.8,
Fern Testing,30087205,CDM,300,RC,87205,CPT,,,Outpatient,,,45,,,,80,,36,percent of total billed charges,,,,50,7.27,fee schedule,,,77.7,,34.97,percent of total billed charges,,,95,,42.75,percent of total billed charges,,,60,,27,percent of total billed charges,,27,42.75,
Fern Testing,30087205,CDM,300,RC,87205,CPT,,,Inpatient,,,45,,,,80,,36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,34.97,percent of total billed charges,,,95,,42.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,42.75,
KOH 2,30087220,CDM,300,RC,87220,CPT,,,Outpatient,,,50,,,,80,,40,percent of total billed charges,,,,50,9.03,fee schedule,,,77.7,,38.85,percent of total billed charges,,,95,,47.5,percent of total billed charges,,,60,,30,percent of total billed charges,,30,47.5,
KOH 2,30087220,CDM,300,RC,87220,CPT,,,Inpatient,,,50,,,,80,,40,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,38.85,percent of total billed charges,,,95,,47.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,47.5,
Rapid Clostridium Difficile Toxin,30087324,CDM,300,RC,87324,CPT,,,Outpatient,,,151,,,,80,,120.8,percent of total billed charges,,,,50,27.42,fee schedule,,,77.7,,117.33,percent of total billed charges,,,95,,143.45,percent of total billed charges,,,60,,90.6,percent of total billed charges,,90.6,143.45,
Rapid Clostridium Difficile Toxin,30087324,CDM,300,RC,87324,CPT,,,Inpatient,,,151,,,,80,,120.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,117.33,percent of total billed charges,,,95,,143.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,143.45,
"Rotavirus Ag, EIA - LC",30087425,CDM,300,RC,87425,CPT,,,Outpatient,,,90,,,,80,,72,percent of total billed charges,,,,50,27.42,fee schedule,,,77.7,,69.93,percent of total billed charges,,,95,,85.5,percent of total billed charges,,,60,,54,percent of total billed charges,,54,85.5,
"Rotavirus Ag, EIA - LC",30087425,CDM,300,RC,87425,CPT,,,Inpatient,,,90,,,,80,,72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,69.93,percent of total billed charges,,,95,,85.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,85.5,
COVID-19 SARS Ag,30087426,CDM,300,RC,87426,CPT,,,Outpatient,,,97,,,,80,,77.6,percent of total billed charges,,,,50,27.42,fee schedule,,,77.7,,75.37,percent of total billed charges,,,95,,92.15,percent of total billed charges,,,60,,58.2,percent of total billed charges,,58.2,92.15,
COVID-19 SARS Ag,30087426,CDM,300,RC,87426,CPT,,,Inpatient,,,97,,,,80,,77.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,75.37,percent of total billed charges,,,95,,92.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,92.15,
Affirm Vaginitis Panel,30087480,CDM,300,RC,87480,CPT,,,Outpatient,,,43,,,,80,,34.4,percent of total billed charges,,,,50,29.05,fee schedule,,,77.7,,33.41,percent of total billed charges,,,95,,40.85,percent of total billed charges,,,60,,25.8,percent of total billed charges,,25.8,40.85,
Affirm Vaginitis Panel,30087480,CDM,300,RC,87480,CPT,,,Inpatient,,,43,,,,80,,34.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,33.41,percent of total billed charges,,,95,,40.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,40.85,
Chlamydia by PCR,30087491,CDM,300,RC,87491,CPT,,,Outpatient,,,131,,,,80,,104.8,percent of total billed charges,,,,50,37.66,fee schedule,,,77.7,,101.79,percent of total billed charges,,,95,,124.45,percent of total billed charges,,,60,,78.6,percent of total billed charges,,78.6,124.45,
GC / Chlamydia  by PCR,30087491,CDM,300,RC,87491,CPT,,,Outpatient,,,131,,,,80,,104.8,percent of total billed charges,,,,50,37.66,fee schedule,,,77.7,,101.79,percent of total billed charges,,,95,,124.45,percent of total billed charges,,,60,,78.6,percent of total billed charges,,78.6,124.45,
Chlamydia by PCR,30087491,CDM,300,RC,87491,CPT,,,Inpatient,,,131,,,,80,,104.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,101.79,percent of total billed charges,,,95,,124.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,124.45,
GC / Chlamydia  by PCR,30087491,CDM,300,RC,87491,CPT,,,Inpatient,,,131,,,,80,,104.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,101.79,percent of total billed charges,,,95,,124.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,124.45,
Influenza A/B - Molecular,30087502,CDM,300,RC,87502,CPT,,,Outpatient,,,240,,,,80,,192,percent of total billed charges,,,,50,55.89,fee schedule,,,77.7,,186.48,percent of total billed charges,,,95,,228,percent of total billed charges,,,60,,144,percent of total billed charges,,144,228,
Influenza by PCR,30087502,CDM,300,RC,87502,CPT,,,Outpatient,,,240,,,,80,,192,percent of total billed charges,,,,50,55.89,fee schedule,,,77.7,,186.48,percent of total billed charges,,,95,,228,percent of total billed charges,,,60,,144,percent of total billed charges,,144,228,
Influenza A/B - Molecular,30087502,CDM,300,RC,87502,CPT,,,Inpatient,,,240,,,,80,,192,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,186.48,percent of total billed charges,,,95,,228,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,228,
Influenza by PCR,30087502,CDM,300,RC,87502,CPT,,,Inpatient,,,240,,,,80,,192,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,186.48,percent of total billed charges,,,95,,228,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,228,
87510 Gardnerella vaginalis,30087510,CDM,300,RC,87510,CPT,,,Outpatient,,,43,,,,80,,34.4,percent of total billed charges,,,,50,29.05,fee schedule,,,77.7,,33.41,percent of total billed charges,,,95,,40.85,percent of total billed charges,,,60,,25.8,percent of total billed charges,,25.8,40.85,
87510 Gardnerella vaginalis,30087510,CDM,300,RC,87510,CPT,,,Inpatient,,,43,,,,80,,34.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,33.41,percent of total billed charges,,,95,,40.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,40.85,
87591 IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ,30087591,CDM,300,RC,87591,CPT,,,Outpatient,,,110,,,,80,,88,percent of total billed charges,,,,50,37.66,fee schedule,,,77.7,,85.47,percent of total billed charges,,,95,,104.5,percent of total billed charges,,,60,,66,percent of total billed charges,,66,104.5,
GC by PCR,30087591,CDM,300,RC,87591,CPT,,,Outpatient,,,110,,,,80,,88,percent of total billed charges,,,,50,37.66,fee schedule,,,77.7,,85.47,percent of total billed charges,,,95,,104.5,percent of total billed charges,,,60,,66,percent of total billed charges,,66,104.5,
87591 IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ,30087591,CDM,300,RC,87591,CPT,,,Inpatient,,,110,,,,80,,88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,85.47,percent of total billed charges,,,95,,104.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,104.5,
GC by PCR,30087591,CDM,300,RC,87591,CPT,,,Inpatient,,,110,,,,80,,88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,85.47,percent of total billed charges,,,95,,104.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,104.5,
RSV - Molecular,30087634,CDM,300,RC,87634,CPT,,,Outpatient,,,203,,,,80,,162.4,percent of total billed charges,,,,50,78.78,fee schedule,,,77.7,,157.73,percent of total billed charges,,,95,,192.85,percent of total billed charges,,,60,,121.8,percent of total billed charges,,121.8,192.85,
RSV - Molecular,30087634,CDM,300,RC,87634,CPT,,,Inpatient,,,203,,,,80,,162.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,157.73,percent of total billed charges,,,95,,192.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,192.85,
SARS-CoV-2 by PCR,30087635,CDM,300,RC,87635,CPT,,,Outpatient,,,202,,,,80,,161.6,percent of total billed charges,,,,50,57.09,fee schedule,,,77.7,,156.95,percent of total billed charges,,,95,,191.9,percent of total billed charges,,,60,,121.2,percent of total billed charges,,121.2,191.9,
SARS-CoV-2 by PCR,30087635,CDM,300,RC,87635,CPT,,,Inpatient,,,202,,,,80,,161.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,156.95,percent of total billed charges,,,95,,191.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,191.9,
Strep A - Molecular,30087651,CDM,300,RC,87651,CPT,,,Outpatient,,,145,,,,80,,116,percent of total billed charges,,,,50,37.66,fee schedule,,,77.7,,112.67,percent of total billed charges,,,95,,137.75,percent of total billed charges,,,60,,87,percent of total billed charges,,87,137.75,
Strep A - Molecular,30087651,CDM,300,RC,87651,CPT,,,Inpatient,,,145,,,,80,,116,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,112.67,percent of total billed charges,,,95,,137.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,137.75,
Group B Strep Screen,30087653,CDM,300,RC,87653,CPT,,,Outpatient,,,129,,,,80,,103.2,percent of total billed charges,,,,50,37.66,fee schedule,,,77.7,,100.23,percent of total billed charges,,,95,,122.55,percent of total billed charges,,,60,,77.4,percent of total billed charges,,77.4,122.55,
Group B Strep Screen,30087653,CDM,300,RC,87653,CPT,,,Inpatient,,,129,,,,80,,103.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,100.23,percent of total billed charges,,,95,,122.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,122.55,
87660 Trichomonas vaginalis,30087660,CDM,300,RC,87660,CPT,,,Outpatient,,,43,,,,80,,34.4,percent of total billed charges,,,,50,28.95,fee schedule,,,77.7,,33.41,percent of total billed charges,,,95,,40.85,percent of total billed charges,,,60,,25.8,percent of total billed charges,,25.8,40.85,
87660 Trichomonas vaginalis,30087660,CDM,300,RC,87660,CPT,,,Inpatient,,,43,,,,80,,34.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,33.41,percent of total billed charges,,,95,,40.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,40.85,
Trichomonas vaginalis by PCR,30087661,CDM,300,RC,87661,CPT,,,Outpatient,,,119,,,,80,,95.2,percent of total billed charges,,,,50,47.75,fee schedule,,,77.7,,92.46,percent of total billed charges,,,95,,113.05,percent of total billed charges,,,60,,71.4,percent of total billed charges,,71.4,113.05,
Trichomonas vaginalis by PCR,30087661,CDM,300,RC,87661,CPT,,,Inpatient,,,119,,,,80,,95.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,92.46,percent of total billed charges,,,95,,113.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,113.05,
Acute Viral Hepatitis - LC,30980074,CDM,309,RC,80074,CPT,,,Outpatient,,,172,,,,80,,137.6,percent of total billed charges,,,,50,69,fee schedule,,,77.7,,133.64,percent of total billed charges,,,95,,163.4,percent of total billed charges,,,60,,103.2,percent of total billed charges,,103.2,163.4,
Acute Viral Hepatitis - LC,30980074,CDM,309,RC,80074,CPT,,,Inpatient,,,172,,,,80,,137.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,133.64,percent of total billed charges,,,95,,163.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,163.4,
Acetaminophen - LC,30980143,CDM,309,RC,80143,CPT,,,Outpatient,,,110,,,,80,,88,percent of total billed charges,,,,50,14.55,fee schedule,,,77.7,,85.47,percent of total billed charges,,,95,,104.5,percent of total billed charges,,,60,,66,percent of total billed charges,,66,104.5,
Acetaminophen - LC,30980143,CDM,309,RC,80143,CPT,,,Inpatient,,,110,,,,80,,88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,85.47,percent of total billed charges,,,95,,104.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,104.5,
Adalimumab Concentration and Ab (Serial Monitor) - LC,30980145,CDM,309,RC,80145,CPT,,,Outpatient,,,460,,,,80,,368,percent of total billed charges,,,,85,391,percent of total billed charges,,,77.7,,357.42,percent of total billed charges,,,95,,437,percent of total billed charges,,,60,,276,percent of total billed charges,,276,437,
Adalimumab Concentration and Ab (Serial Monitor) - LC,30980145,CDM,309,RC,80145,CPT,,,Inpatient,,,460,,,,80,,368,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,357.42,percent of total billed charges,,,95,,437,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,437,
"Cyclosporine, Blood - LC",30980158,CDM,309,RC,80158,CPT,,,Outpatient,,,223,,,,80,,178.4,percent of total billed charges,,,,50,35.59,fee schedule,,,77.7,,173.27,percent of total billed charges,,,95,,211.85,percent of total billed charges,,,60,,133.8,percent of total billed charges,,133.8,211.85,
"Cyclosporine, Blood - LC",30980158,CDM,309,RC,80158,CPT,,,Inpatient,,,223,,,,80,,178.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,173.27,percent of total billed charges,,,95,,211.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,211.85,
"Clozapine (Clozaril), Serum - LC",30980159,CDM,309,RC,80159,CPT,,,Outpatient,,,239,,,,80,,191.2,percent of total billed charges,,,,50,25.17,fee schedule,,,77.7,,185.7,percent of total billed charges,,,95,,227.05,percent of total billed charges,,,60,,143.4,percent of total billed charges,,143.4,227.05,
"Clozapine (Clozaril), Serum - LC",30980159,CDM,309,RC,80159,CPT,,,Inpatient,,,239,,,,80,,191.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,185.7,percent of total billed charges,,,95,,227.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,227.05,
Digoxin - LC,30980162,CDM,309,RC,80162,CPT,,,Outpatient,,,142,,,,80,,113.6,percent of total billed charges,,,,50,27.2,fee schedule,,,77.7,,110.33,percent of total billed charges,,,95,,134.9,percent of total billed charges,,,60,,85.2,percent of total billed charges,,85.2,134.9,
Digoxin - LC,30980162,CDM,309,RC,80162,CPT,,,Inpatient,,,142,,,,80,,113.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,110.33,percent of total billed charges,,,95,,134.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,134.9,
"Ethosuximide (Zarontin), Serum LC",30980168,CDM,309,RC,80168,CPT,,,Outpatient,,,85,,,,80,,68,percent of total billed charges,,,,50,24.8,fee schedule,,,77.7,,66.05,percent of total billed charges,,,95,,80.75,percent of total billed charges,,,60,,51,percent of total billed charges,,51,80.75,
"Ethosuximide (Zarontin), Serum LC",30980168,CDM,309,RC,80168,CPT,,,Inpatient,,,85,,,,80,,68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,66.05,percent of total billed charges,,,95,,80.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,80.75,
"Gentamicin Peak, Serum - LC",30980170,CDM,309,RC,80170,CPT,,,Outpatient,,,150,,,,80,,120,percent of total billed charges,,,,50,28.71,fee schedule,,,77.7,,116.55,percent of total billed charges,,,95,,142.5,percent of total billed charges,,,60,,90,percent of total billed charges,,90,142.5,
"Gentamicin Random, Serum - LC",30980170,CDM,309,RC,80170,CPT,,,Outpatient,,,150,,,,80,,120,percent of total billed charges,,,,50,28.71,fee schedule,,,77.7,,116.55,percent of total billed charges,,,95,,142.5,percent of total billed charges,,,60,,90,percent of total billed charges,,90,142.5,
"Gentamicin Trough, Serum - LC",30980170,CDM,309,RC,80170,CPT,,,Outpatient,,,150,,,,80,,120,percent of total billed charges,,,,50,28.71,fee schedule,,,77.7,,116.55,percent of total billed charges,,,95,,142.5,percent of total billed charges,,,60,,90,percent of total billed charges,,90,142.5,
"Gentamicin Peak, Serum - LC",30980170,CDM,309,RC,80170,CPT,,,Inpatient,,,150,,,,80,,120,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,116.55,percent of total billed charges,,,95,,142.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,142.5,
"Gentamicin Random, Serum - LC",30980170,CDM,309,RC,80170,CPT,,,Inpatient,,,150,,,,80,,120,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,116.55,percent of total billed charges,,,95,,142.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,142.5,
"Gentamicin Trough, Serum - LC",30980170,CDM,309,RC,80170,CPT,,,Inpatient,,,150,,,,80,,120,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,116.55,percent of total billed charges,,,95,,142.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,142.5,
"Lamotrigine (Lamictal), Serum LC",30980175,CDM,309,RC,80175,CPT,,,Outpatient,,,70,,,,80,,56,percent of total billed charges,,,,50,18.23,fee schedule,,,77.7,,54.39,percent of total billed charges,,,95,,66.5,percent of total billed charges,,,60,,42,percent of total billed charges,,42,66.5,
"Lamotrigine (Lamictal), Serum LC",30980175,CDM,309,RC,80175,CPT,,,Inpatient,,,70,,,,80,,56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,54.39,percent of total billed charges,,,95,,66.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,66.5,
"Levetiracetam (Keppra), S LC",30980177,CDM,309,RC,80177,CPT,,,Outpatient,,,70,,,,80,,56,percent of total billed charges,,,,50,18.23,fee schedule,,,77.7,,54.39,percent of total billed charges,,,95,,66.5,percent of total billed charges,,,60,,42,percent of total billed charges,,42,66.5,
"Levetiracetam (Keppra), S LC",30980177,CDM,309,RC,80177,CPT,,,Inpatient,,,70,,,,80,,56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,54.39,percent of total billed charges,,,95,,66.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,66.5,
Salicylates - LC,30980179,CDM,309,RC,80179,CPT,,,Outpatient,,,72,,,,80,,57.6,percent of total billed charges,,,,50,14.55,fee schedule,,,77.7,,55.94,percent of total billed charges,,,95,,68.4,percent of total billed charges,,,60,,43.2,percent of total billed charges,,43.2,68.4,
Salicylates - LC,30980179,CDM,309,RC,80179,CPT,,,Inpatient,,,72,,,,80,,57.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,55.94,percent of total billed charges,,,95,,68.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,68.4,
80184 Assay of phenobarbital LC,30980184,CDM,309,RC,80184,CPT,,,Outpatient,,,142,,,,80,,113.6,percent of total billed charges,,,,50,27,fee schedule,,,77.7,,110.33,percent of total billed charges,,,95,,134.9,percent of total billed charges,,,60,,85.2,percent of total billed charges,,85.2,134.9,
80184 Assay of phenobarbital LC,30980184,CDM,309,RC,80184,CPT,,,Inpatient,,,142,,,,80,,113.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,110.33,percent of total billed charges,,,95,,134.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,134.9,
Zonisamide (Zonegran) - LC,30980203,CDM,309,RC,80203,CPT,,,Outpatient,,,75,,,,80,,60,percent of total billed charges,,,,50,18.04,fee schedule,,,77.7,,58.28,percent of total billed charges,,,95,,71.25,percent of total billed charges,,,60,,45,percent of total billed charges,,45,71.25,
Zonisamide (Zonegran) - LC,30980203,CDM,309,RC,80203,CPT,,,Inpatient,,,75,,,,80,,60,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,58.28,percent of total billed charges,,,95,,71.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,71.25,
"Amantadine, Serum or Plasma - LC",30980299,CDM,309,RC,80299,CPT,,,Outpatient,,,173,,,,80,,138.4,percent of total billed charges,,,,50,32.86,fee schedule,,,77.7,,134.42,percent of total billed charges,,,95,,164.35,percent of total billed charges,,,60,,103.8,percent of total billed charges,,103.8,164.35,
"Desipramine, Serum LC",30980299,CDM,309,RC,80299,CPT,,,Outpatient,,,173,,,,80,,138.4,percent of total billed charges,,,,50,32.86,fee schedule,,,77.7,,134.42,percent of total billed charges,,,95,,164.35,percent of total billed charges,,,60,,103.8,percent of total billed charges,,103.8,164.35,
"Dexamethasone, Serum - LC",30980299,CDM,309,RC,80299,CPT,,,Outpatient,,,100,,,,80,,80,percent of total billed charges,,,,50,32.86,fee schedule,,,77.7,,77.7,percent of total billed charges,,,95,,95,percent of total billed charges,,,60,,60,percent of total billed charges,,60,95,
"Amantadine, Serum or Plasma - LC",30980299,CDM,309,RC,80299,CPT,,,Inpatient,,,173,,,,80,,138.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,134.42,percent of total billed charges,,,95,,164.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,164.35,
"Desipramine, Serum LC",30980299,CDM,309,RC,80299,CPT,,,Inpatient,,,173,,,,80,,138.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,134.42,percent of total billed charges,,,95,,164.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,164.35,
"Dexamethasone, Serum - LC",30980299,CDM,309,RC,80299,CPT,,,Inpatient,,,100,,,,80,,80,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,77.7,percent of total billed charges,,,95,,95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,95,
726778 7+Alc-Unbund LC,30980307,CDM,309,RC,80307,CPT,,,Outpatient,,,187,,,,80,,149.6,percent of total billed charges,,,,50,75.04,fee schedule,,,77.7,,145.3,percent of total billed charges,,,95,,177.65,percent of total billed charges,,,60,,112.2,percent of total billed charges,,112.2,177.65,
"Acetyl Fentanyl, Urine - LC",30980307,CDM,309,RC,80307,CPT,,,Outpatient,,,187,,,,80,,149.6,percent of total billed charges,,,,50,75.04,fee schedule,,,77.7,,145.3,percent of total billed charges,,,95,,177.65,percent of total billed charges,,,60,,112.2,percent of total billed charges,,112.2,177.65,
"Drug Screen 13 w/ Rflx Conf., Meconium - LC",30980307,CDM,309,RC,80307,CPT,,,Outpatient,,,250,,,,80,,200,percent of total billed charges,,,,50,75.04,fee schedule,,,77.7,,194.25,percent of total billed charges,,,95,,237.5,percent of total billed charges,,,60,,150,percent of total billed charges,,150,237.5,
"Drug Screen 8 w/Conf, WB LC",30980307,CDM,309,RC,80307,CPT,,,Outpatient,,,300,,,,80,,240,percent of total billed charges,,,,50,75.04,fee schedule,,,77.7,,233.1,percent of total billed charges,,,95,,285,percent of total billed charges,,,60,,180,percent of total billed charges,,180,285,
"Nicotine Metabolite, Urine - LC",30980307,CDM,309,RC,80307,CPT,,,Outpatient,,,187,,,,80,,149.6,percent of total billed charges,,,,50,75.04,fee schedule,,,77.7,,145.3,percent of total billed charges,,,95,,177.65,percent of total billed charges,,,60,,112.2,percent of total billed charges,,112.2,177.65,
"Opiates Confirmation, Urine - LC",30980307,CDM,309,RC,80307,CPT,,,Outpatient,,,225,,,,80,,180,percent of total billed charges,,,,50,75.04,fee schedule,,,77.7,,174.83,percent of total billed charges,,,95,,213.75,percent of total billed charges,,,60,,135,percent of total billed charges,,135,213.75,
726778 7+Alc-Unbund LC,30980307,CDM,309,RC,80307,CPT,,,Inpatient,,,187,,,,80,,149.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,145.3,percent of total billed charges,,,95,,177.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,177.65,
"Acetyl Fentanyl, Urine - LC",30980307,CDM,309,RC,80307,CPT,,,Inpatient,,,187,,,,80,,149.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,145.3,percent of total billed charges,,,95,,177.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,177.65,
"Drug Screen 13 w/ Rflx Conf., Meconium - LC",30980307,CDM,309,RC,80307,CPT,,,Inpatient,,,250,,,,80,,200,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,194.25,percent of total billed charges,,,95,,237.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,237.5,
"Drug Screen 8 w/Conf, WB LC",30980307,CDM,309,RC,80307,CPT,,,Inpatient,,,300,,,,80,,240,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,233.1,percent of total billed charges,,,95,,285,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,285,
"Nicotine Metabolite, Urine - LC",30980307,CDM,309,RC,80307,CPT,,,Inpatient,,,187,,,,80,,149.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,145.3,percent of total billed charges,,,95,,177.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,177.65,
"Opiates Confirmation, Urine - LC",30980307,CDM,309,RC,80307,CPT,,,Inpatient,,,225,,,,80,,180,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,174.83,percent of total billed charges,,,95,,213.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,213.75,
.Meconium ETG/ETS Confirmation - LC,30980321,CDM,309,RC,80321,CPT,,,Outpatient,,,75,,,,80,,60,percent of total billed charges,,,,50,23.2,fee schedule,,,77.7,,58.28,percent of total billed charges,,,95,,71.25,percent of total billed charges,,,60,,45,percent of total billed charges,,45,71.25,
.Meconium ETG/ETS Confirmation - LC,30980321,CDM,309,RC,80321,CPT,,,Inpatient,,,75,,,,80,,60,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,58.28,percent of total billed charges,,,95,,71.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,71.25,
"Nicotine and Metabolite, Quant LC",30980323,CDM,309,RC,80323,CPT,,,Outpatient,,,130,,,,80,,104,percent of total billed charges,,,,50,18.03,fee schedule,,,77.7,,101.01,percent of total billed charges,,,95,,123.5,percent of total billed charges,,,60,,78,percent of total billed charges,,78,123.5,
"Nicotine and Metabolite, Ur Qn - LC",30980323,CDM,309,RC,80323,CPT,,,Outpatient,,,130,,,,80,,104,percent of total billed charges,,,,50,18.03,fee schedule,,,77.7,,101.01,percent of total billed charges,,,95,,123.5,percent of total billed charges,,,60,,78,percent of total billed charges,,78,123.5,
"Nicotine and Metabolite, Quant LC",30980323,CDM,309,RC,80323,CPT,,,Inpatient,,,130,,,,80,,104,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,101.01,percent of total billed charges,,,95,,123.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,123.5,
"Nicotine and Metabolite, Ur Qn - LC",30980323,CDM,309,RC,80323,CPT,,,Inpatient,,,130,,,,80,,104,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,101.01,percent of total billed charges,,,95,,123.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,123.5,
80324 Drug screen amphetamines 1/2 LC,30980324,CDM,309,RC,80324,CPT,,,Outpatient,,,56,,,,80,,44.8,percent of total billed charges,,,,50,18.57,fee schedule,,,77.7,,43.51,percent of total billed charges,,,95,,53.2,percent of total billed charges,,,60,,33.6,percent of total billed charges,,33.6,53.2,
.Meconium Amphet Confirmation - LC,30980324,CDM,309,RC,80324,CPT,,,Outpatient,,,65,,,,80,,52,percent of total billed charges,,,,50,18.57,fee schedule,,,77.7,,50.51,percent of total billed charges,,,95,,61.75,percent of total billed charges,,,60,,39,percent of total billed charges,,39,61.75,
80324 Drug screen amphetamines 1/2 LC,30980324,CDM,309,RC,80324,CPT,,,Inpatient,,,56,,,,80,,44.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,43.51,percent of total billed charges,,,95,,53.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,53.2,
.Meconium Amphet Confirmation - LC,30980324,CDM,309,RC,80324,CPT,,,Inpatient,,,65,,,,80,,52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,50.51,percent of total billed charges,,,95,,61.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,61.75,
"Barbiturate Confirmation, Ur LC",30980345,CDM,309,RC,80345,CPT,,,Outpatient,,,144,,,,80,,115.2,percent of total billed charges,,,,50,27.71,fee schedule,,,77.7,,111.89,percent of total billed charges,,,95,,136.8,percent of total billed charges,,,60,,86.4,percent of total billed charges,,86.4,136.8,
"Barbiturate Confirmation, Ur LC",30980345,CDM,309,RC,80345,CPT,,,Inpatient,,,144,,,,80,,115.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,111.89,percent of total billed charges,,,95,,136.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,136.8,
"Benzodiazepines Confirm, Urine LC",30980346,CDM,309,RC,80346,CPT,,,Outpatient,,,68,,,,80,,54.4,percent of total billed charges,,,,50,27.38,fee schedule,,,77.7,,52.84,percent of total billed charges,,,95,,64.6,percent of total billed charges,,,60,,40.8,percent of total billed charges,,40.8,64.6,
"Benzodiazepines Confirm, Urine LC",30980346,CDM,309,RC,80346,CPT,,,Inpatient,,,68,,,,80,,54.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,52.84,percent of total billed charges,,,95,,64.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,64.6,
.Meconium Carboxy-THC Confirmation - LC,30980349,CDM,309,RC,80349,CPT,,,Outpatient,,,45,,,,80,,36,percent of total billed charges,,,,50,11.94,fee schedule,,,77.7,,34.97,percent of total billed charges,,,95,,42.75,percent of total billed charges,,,60,,27,percent of total billed charges,,27,42.75,
"Cannabinoid Confirmation, Ur LC",30980349,CDM,309,RC,80349,CPT,,,Outpatient,,,56,,,,80,,44.8,percent of total billed charges,,,,50,11.94,fee schedule,,,77.7,,43.51,percent of total billed charges,,,95,,53.2,percent of total billed charges,,,60,,33.6,percent of total billed charges,,33.6,53.2,
.Meconium Carboxy-THC Confirmation - LC,30980349,CDM,309,RC,80349,CPT,,,Inpatient,,,45,,,,80,,36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,34.97,percent of total billed charges,,,95,,42.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,42.75,
"Cannabinoid Confirmation, Ur LC",30980349,CDM,309,RC,80349,CPT,,,Inpatient,,,56,,,,80,,44.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,43.51,percent of total billed charges,,,95,,53.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,53.2,
.Meconium Cocaine Confirmation - LC,30980353,CDM,309,RC,80353,CPT,,,Outpatient,,,70,,,,80,,56,percent of total billed charges,,,,50,17.5,fee schedule,,,77.7,,54.39,percent of total billed charges,,,95,,66.5,percent of total billed charges,,,60,,42,percent of total billed charges,,42,66.5,
.Meconium Cocaine Confirmation - LC,30980353,CDM,309,RC,80353,CPT,,,Inpatient,,,70,,,,80,,56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,54.39,percent of total billed charges,,,95,,66.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,66.5,
80356 Heroin metabolite LC,30980356,CDM,309,RC,80356,CPT,,,Outpatient,,,45,,,,80,,36,percent of total billed charges,,,,50,11.94,fee schedule,,,77.7,,34.97,percent of total billed charges,,,95,,42.75,percent of total billed charges,,,60,,27,percent of total billed charges,,27,42.75,
80356 Heroin metabolite LC,30980356,CDM,309,RC,80356,CPT,,,Inpatient,,,45,,,,80,,36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,34.97,percent of total billed charges,,,95,,42.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,42.75,
.Meconium Opiate Confirmation - LC,30980361,CDM,309,RC,80361,CPT,,,Outpatient,,,70,,,,80,,56,percent of total billed charges,,,,50,21.34,fee schedule,,,77.7,,54.39,percent of total billed charges,,,95,,66.5,percent of total billed charges,,,60,,42,percent of total billed charges,,42,66.5,
.Meconium Opiate Confirmation - LC,30980361,CDM,309,RC,80361,CPT,,,Inpatient,,,70,,,,80,,56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,54.39,percent of total billed charges,,,95,,66.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,66.5,
"Cystic Fibrosis(CF) Profile, 32 Mutations, DNA Analysis - LC",30981220,CDM,309,RC,81220,CPT,,,Outpatient,,,1300,,,,80,,1040,percent of total billed charges,,,,50,1185.62,fee schedule,,,77.7,,1010.1,percent of total billed charges,,,95,,1235,percent of total billed charges,,,60,,780,percent of total billed charges,,780,1235,
"Cystic Fibrosis(CF) Profile, 32 Mutations, DNA Analysis - LC",30981220,CDM,309,RC,81220,CPT,,,Inpatient,,,1300,,,,80,,1040,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1010.1,percent of total billed charges,,,95,,1235,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1235,
"Factor II, DNA Analysis LC",30981240,CDM,309,RC,81240,CPT,,,Outpatient,,,198,,,,80,,158.4,percent of total billed charges,,,,50,95.09,fee schedule,,,77.7,,153.85,percent of total billed charges,,,95,,188.1,percent of total billed charges,,,60,,118.8,percent of total billed charges,,118.8,188.1,
"Factor II, DNA Analysis LC",30981240,CDM,309,RC,81240,CPT,,,Inpatient,,,198,,,,80,,158.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,153.85,percent of total billed charges,,,95,,188.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,188.1,
Factor V Leiden Mutation LC,30981241,CDM,319,RC,81241,CPT,,,Outpatient,,,275,,,,80,,220,percent of total billed charges,,,,50,87.57,fee schedule,,,77.7,,213.68,percent of total billed charges,,,95,,261.25,percent of total billed charges,,,60,,165,percent of total billed charges,,165,261.25,
Factor V Leiden Mutation LC,30981241,CDM,319,RC,81241,CPT,,,Inpatient,,,275,,,,80,,220,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,213.68,percent of total billed charges,,,95,,261.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,261.25,
HLA B 27 Disease Association LC,30981374,CDM,309,RC,81374,CPT,,,Outpatient,,,127,,,,80,,101.6,percent of total billed charges,,,,50,50.84,fee schedule,,,77.7,,98.68,percent of total billed charges,,,95,,120.65,percent of total billed charges,,,60,,76.2,percent of total billed charges,,76.2,120.65,
HLA B 27 Disease Association LC,30981374,CDM,309,RC,81374,CPT,,,Inpatient,,,127,,,,80,,101.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,98.68,percent of total billed charges,,,95,,120.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,120.65,
81377 HLA Typing,30981377,CDM,309,RC,81377,CPT,,,Outpatient,,,307,,,,80,,245.6,percent of total billed charges,,,,50,176.55,fee schedule,,,77.7,,238.54,percent of total billed charges,,,95,,291.65,percent of total billed charges,,,60,,184.2,percent of total billed charges,,184.2,291.65,
Celiac Disease HLA DQ Assoc. - LC,30981377,CDM,309,RC,81377,CPT,,,Outpatient,,,307,,,,80,,245.6,percent of total billed charges,,,,50,176.55,fee schedule,,,77.7,,238.54,percent of total billed charges,,,95,,291.65,percent of total billed charges,,,60,,184.2,percent of total billed charges,,184.2,291.65,
81377 HLA Typing,30981377,CDM,309,RC,81377,CPT,,,Inpatient,,,307,,,,80,,245.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,238.54,percent of total billed charges,,,95,,291.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,291.65,
Celiac Disease HLA DQ Assoc. - LC,30981377,CDM,309,RC,81377,CPT,,,Inpatient,,,307,,,,80,,245.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,238.54,percent of total billed charges,,,95,,291.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,291.65,
.Factor V R2 DNA Analysis - LC,30981400,CDM,310,RC,81400,CPT,,,Outpatient,,,145,,,,80,,116,percent of total billed charges,,,,50,44.63,fee schedule,,,77.7,,112.67,percent of total billed charges,,,95,,137.75,percent of total billed charges,,,60,,87,percent of total billed charges,,87,137.75,
.Factor V R2 DNA Analysis - LC,30981400,CDM,310,RC,81400,CPT,,,Inpatient,,,145,,,,80,,116,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,112.67,percent of total billed charges,,,95,,137.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,137.75,
Beta-Hydroxybutyrate LC,30982010,CDM,309,RC,82010,CPT,,,Outpatient,,,95,,,,80,,76,percent of total billed charges,,,,50,14.53,fee schedule,,,77.7,,73.82,percent of total billed charges,,,95,,90.25,percent of total billed charges,,,60,,57,percent of total billed charges,,57,90.25,
Beta-Hydroxybutyrate LC,30982010,CDM,309,RC,82010,CPT,,,Inpatient,,,95,,,,80,,76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,73.82,percent of total billed charges,,,95,,90.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,90.25,
Aldolase LC,30982085,CDM,309,RC,82085,CPT,,,Outpatient,,,85,,,,80,,68,percent of total billed charges,,,,50,16.11,fee schedule,,,77.7,,66.05,percent of total billed charges,,,95,,80.75,percent of total billed charges,,,60,,51,percent of total billed charges,,51,80.75,
Aldolase LC,30982085,CDM,309,RC,82085,CPT,,,Inpatient,,,85,,,,80,,68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,66.05,percent of total billed charges,,,95,,80.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,80.75,
82088 Assay of aldosterone LC,30982088,CDM,309,RC,82088,CPT,,,Outpatient,,,302,,,,80,,241.6,percent of total billed charges,,,,50,61.6,fee schedule,,,77.7,,234.65,percent of total billed charges,,,95,,286.9,percent of total billed charges,,,60,,181.2,percent of total billed charges,,181.2,286.9,
"Aldosterone LCMS, Serum - LC",30982088,CDM,309,RC,82088,CPT,,,Outpatient,,,302,,,,80,,241.6,percent of total billed charges,,,,50,61.6,fee schedule,,,77.7,,234.65,percent of total billed charges,,,95,,286.9,percent of total billed charges,,,60,,181.2,percent of total billed charges,,181.2,286.9,
Renin Activity and Aldosterone LC,30982088,CDM,309,RC,82088,CPT,,,Outpatient,,,160,,,,80,,128,percent of total billed charges,,,,50,61.6,fee schedule,,,77.7,,124.32,percent of total billed charges,,,95,,152,percent of total billed charges,,,60,,96,percent of total billed charges,,96,152,
82088 Assay of aldosterone LC,30982088,CDM,309,RC,82088,CPT,,,Inpatient,,,302,,,,80,,241.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,234.65,percent of total billed charges,,,95,,286.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,286.9,
"Aldosterone LCMS, Serum - LC",30982088,CDM,309,RC,82088,CPT,,,Inpatient,,,302,,,,80,,241.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,234.65,percent of total billed charges,,,95,,286.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,286.9,
Renin Activity and Aldosterone LC,30982088,CDM,309,RC,82088,CPT,,,Inpatient,,,160,,,,80,,128,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,124.32,percent of total billed charges,,,95,,152,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,152,
Alpha-1-Antitrypsin Phenotyp LC,30982103,CDM,309,RC,82103,CPT,,,Outpatient,,,141,,,,80,,112.8,percent of total billed charges,,,,50,25.4,fee schedule,,,77.7,,109.56,percent of total billed charges,,,95,,133.95,percent of total billed charges,,,60,,84.6,percent of total billed charges,,84.6,133.95,
Alpha-1-Antitrypsin Phenotyp LC,30982103,CDM,309,RC,82103,CPT,,,Inpatient,,,141,,,,80,,112.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,109.56,percent of total billed charges,,,95,,133.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,133.95,
82104 Alpha-1-antitrypsin pheno LC,30982104,CDM,309,RC,82104,CPT,,,Outpatient,,,141,,,,80,,112.8,percent of total billed charges,,,,50,41.26,fee schedule,,,77.7,,109.56,percent of total billed charges,,,95,,133.95,percent of total billed charges,,,60,,84.6,percent of total billed charges,,84.6,133.95,
82104 Alpha-1-antitrypsin pheno LC,30982104,CDM,309,RC,82104,CPT,,,Inpatient,,,141,,,,80,,112.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,109.56,percent of total billed charges,,,95,,133.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,133.95,
82105 Alpha-fetoprotein serum LC,30982105,CDM,309,RC,82105,CPT,,,Outpatient,,,158,,,,80,,126.4,percent of total billed charges,,,,50,27.82,fee schedule,,,77.7,,122.77,percent of total billed charges,,,95,,150.1,percent of total billed charges,,,60,,94.8,percent of total billed charges,,94.8,150.1,
82105 Alpha-fetoprotein serum LC,30982105,CDM,309,RC,82105,CPT,,,Inpatient,,,158,,,,80,,126.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,122.77,percent of total billed charges,,,95,,150.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,150.1,
Androstenedione LCMS LC,30982157,CDM,309,RC,82157,CPT,,,Outpatient,,,320,,,,80,,256,percent of total billed charges,,,,50,59.56,fee schedule,,,77.7,,248.64,percent of total billed charges,,,95,,304,percent of total billed charges,,,60,,192,percent of total billed charges,,192,304,
Androstenedione LCMS LC,30982157,CDM,309,RC,82157,CPT,,,Inpatient,,,320,,,,80,,256,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,248.64,percent of total billed charges,,,95,,304,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,304,
Angiotensin-Converting Enzyme - LC,30982164,CDM,309,RC,82164,CPT,,,Outpatient,,,122,,,,80,,97.6,percent of total billed charges,,,,50,24.69,fee schedule,,,77.7,,94.79,percent of total billed charges,,,95,,115.9,percent of total billed charges,,,60,,73.2,percent of total billed charges,,73.2,115.9,
Angiotensin-Converting Enzyme - LC,30982164,CDM,309,RC,82164,CPT,,,Inpatient,,,122,,,,80,,97.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,94.79,percent of total billed charges,,,95,,115.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,115.9,
Apolipoprotein B - LC,30982172,CDM,309,RC,82172,CPT,,,Outpatient,,,55,,,,80,,44,percent of total billed charges,,,,50,16.63,fee schedule,,,77.7,,42.74,percent of total billed charges,,,95,,52.25,percent of total billed charges,,,60,,33,percent of total billed charges,,33,52.25,
Apolipoprotein B - LC,30982172,CDM,309,RC,82172,CPT,,,Inpatient,,,55,,,,80,,44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,42.74,percent of total billed charges,,,95,,52.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,52.25,
"Beta-2 Microglobulin, Serum LC",30982232,CDM,309,RC,82232,CPT,,,Outpatient,,,102,,,,80,,81.6,percent of total billed charges,,,,50,21.17,fee schedule,,,77.7,,79.25,percent of total billed charges,,,95,,96.9,percent of total billed charges,,,60,,61.2,percent of total billed charges,,61.2,96.9,
"Beta-2 Microglobulin, Serum LC",30982232,CDM,309,RC,82232,CPT,,,Inpatient,,,102,,,,80,,81.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,79.25,percent of total billed charges,,,95,,96.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,96.9,
82239 BILE ACIDS TOTAL LC,30982239,CDM,309,RC,82239,CPT,,,Outpatient,,,150,,,,80,,120,percent of total billed charges,,,,50,54.2,fee schedule,,,77.7,,116.55,percent of total billed charges,,,95,,142.5,percent of total billed charges,,,60,,90,percent of total billed charges,,90,142.5,
82239 BILE ACIDS TOTAL LC,30982239,CDM,309,RC,82239,CPT,,,Inpatient,,,150,,,,80,,120,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,116.55,percent of total billed charges,,,95,,142.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,142.5,
25-Hydroxyvitamin D LCMS D2+D3 LC,30982306,CDM,309,RC,82306,CPT,,,Outpatient,,,371,,,,80,,296.8,percent of total billed charges,,,,50,109.22,fee schedule,,,77.7,,288.27,percent of total billed charges,,,95,,352.45,percent of total billed charges,,,60,,222.6,percent of total billed charges,,222.6,352.45,
25-Hydroxyvitamin D LCMS D2+D3 LC,30982306,CDM,309,RC,82306,CPT,,,Inpatient,,,371,,,,80,,296.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,288.27,percent of total billed charges,,,95,,352.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,352.45,
Calcitonin - LC,30982308,CDM,309,RC,82308,CPT,,,Outpatient,,,137,,,,80,,109.6,percent of total billed charges,,,,50,51.14,fee schedule,,,77.7,,106.45,percent of total billed charges,,,95,,130.15,percent of total billed charges,,,60,,82.2,percent of total billed charges,,82.2,130.15,
Calcitonin - LC,30982308,CDM,309,RC,82308,CPT,,,Inpatient,,,137,,,,80,,109.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,106.45,percent of total billed charges,,,95,,130.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,130.15,
82310 Calcium,30982310,CDM,309,RC,82310,CPT,,,Outpatient,,,64,,,,80,,51.2,percent of total billed charges,,,,50,5.53,fee schedule,,,77.7,,49.73,percent of total billed charges,,,95,,60.8,percent of total billed charges,,,60,,38.4,percent of total billed charges,,38.4,60.8,
82310 Calcium,30982310,CDM,309,RC,82310,CPT,,,Inpatient,,,64,,,,80,,51.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,49.73,percent of total billed charges,,,95,,60.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,60.8,
Stone Analysis - LC,30982365,CDM,309,RC,82365,CPT,,,Outpatient,,,80,,,,80,,64,percent of total billed charges,,,,50,25.18,fee schedule,,,77.7,,62.16,percent of total billed charges,,,95,,76,percent of total billed charges,,,60,,48,percent of total billed charges,,48,76,
Stone Analysis - LC,30982365,CDM,309,RC,82365,CPT,,,Inpatient,,,80,,,,80,,64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,62.16,percent of total billed charges,,,95,,76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,76,
"Carbon Monoxide, Blood - LC",30982375,CDM,309,RC,82375,CPT,,,Outpatient,,,129,,,,80,,103.2,percent of total billed charges,,,,50,22.94,fee schedule,,,77.7,,100.23,percent of total billed charges,,,95,,122.55,percent of total billed charges,,,60,,77.4,percent of total billed charges,,77.4,122.55,
"Carbon Monoxide, Blood - LC",30982375,CDM,309,RC,82375,CPT,,,Inpatient,,,129,,,,80,,103.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,100.23,percent of total billed charges,,,95,,122.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,122.55,
"Catecholamines, Frac, Ur, Free & VMA 24hr - LC",30982384,CDM,309,RC,82384,CPT,,,Outpatient,,,269,,,,80,,215.2,percent of total billed charges,,,,50,58,fee schedule,,,77.7,,209.01,percent of total billed charges,,,95,,255.55,percent of total billed charges,,,60,,161.4,percent of total billed charges,,161.4,255.55,
"Catecholamines, Fract, Ur Free, Rdm - LC",30982384,CDM,309,RC,82384,CPT,,,Outpatient,,,269,,,,80,,215.2,percent of total billed charges,,,,50,58,fee schedule,,,77.7,,209.01,percent of total billed charges,,,95,,255.55,percent of total billed charges,,,60,,161.4,percent of total billed charges,,161.4,255.55,
"Catecholamines, Frac, Ur, Free & VMA 24hr - LC",30982384,CDM,309,RC,82384,CPT,,,Inpatient,,,269,,,,80,,215.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,209.01,percent of total billed charges,,,95,,255.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,255.55,
"Catecholamines, Fract, Ur Free, Rdm - LC",30982384,CDM,309,RC,82384,CPT,,,Inpatient,,,269,,,,80,,215.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,209.01,percent of total billed charges,,,95,,255.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,255.55,
82397 Anti-Infliximab Antibody,30982397,CDM,309,RC,82397,CPT,,,Outpatient,,,50.81,,,,80,,40.65,percent of total billed charges,,,,50,20.47,fee schedule,,,77.7,,39.48,percent of total billed charges,,,95,,48.27,percent of total billed charges,,,60,,30.49,percent of total billed charges,,30.49,48.27,
Parathyroid Hormone-related Peptide (PTH-rP) - LC,30982397,CDM,309,RC,82397,CPT,,,Outpatient,,,80,,,,80,,64,percent of total billed charges,,,,50,20.47,fee schedule,,,77.7,,62.16,percent of total billed charges,,,95,,76,percent of total billed charges,,,60,,48,percent of total billed charges,,48,76,
82397 Anti-Infliximab Antibody,30982397,CDM,309,RC,82397,CPT,,,Inpatient,,,50.81,,,,80,,40.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,39.48,percent of total billed charges,,,95,,48.27,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,48.27,
Parathyroid Hormone-related Peptide (PTH-rP) - LC,30982397,CDM,309,RC,82397,CPT,,,Inpatient,,,80,,,,80,,64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,62.16,percent of total billed charges,,,95,,76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,76,
"Citric Acid (Citrate), Urine - LC",30982507,CDM,309,RC,82507,CPT,,,Outpatient,,,272,,,,80,,217.6,percent of total billed charges,,,,50,49.95,fee schedule,,,77.7,,211.34,percent of total billed charges,,,95,,258.4,percent of total billed charges,,,60,,163.2,percent of total billed charges,,163.2,258.4,
"Citric Acid (Citrate), Urine - LC",30982507,CDM,309,RC,82507,CPT,,,Inpatient,,,272,,,,80,,217.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,211.34,percent of total billed charges,,,95,,258.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,258.4,
"C-Telopeptide, Serum - LC",30982523,CDM,309,RC,82523,CPT,,,Outpatient,,,67,,,,80,,53.6,percent of total billed charges,,,,50,31.18,fee schedule,,,77.7,,52.06,percent of total billed charges,,,95,,63.65,percent of total billed charges,,,60,,40.2,percent of total billed charges,,40.2,63.65,
"C-Telopeptide, Serum - LC",30982523,CDM,309,RC,82523,CPT,,,Inpatient,,,67,,,,80,,53.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,52.06,percent of total billed charges,,,95,,63.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,63.65,
"Copper, Whole Blood - LC",30982525,CDM,309,RC,82525,CPT,,,Outpatient,,,55,,,,80,,44,percent of total billed charges,,,,50,13.45,fee schedule,,,77.7,,42.74,percent of total billed charges,,,95,,52.25,percent of total billed charges,,,60,,33,percent of total billed charges,,33,52.25,
"Copper, Whole Blood - LC",30982525,CDM,309,RC,82525,CPT,,,Inpatient,,,55,,,,80,,44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,42.74,percent of total billed charges,,,95,,52.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,52.25,
"Cortisol, Urinary Free LC",30982530,CDM,309,RC,82530,CPT,,,Outpatient,,,189,,,,80,,151.2,percent of total billed charges,,,,50,33.26,fee schedule,,,77.7,,146.85,percent of total billed charges,,,95,,179.55,percent of total billed charges,,,60,,113.4,percent of total billed charges,,113.4,179.55,
"Cortisol, Urinary Free LC",30982530,CDM,309,RC,82530,CPT,,,Inpatient,,,189,,,,80,,151.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,146.85,percent of total billed charges,,,95,,179.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,179.55,
Cortisol - LC,30982533,CDM,309,RC,82533,CPT,,,Outpatient,,,167,,,,80,,133.6,percent of total billed charges,,,,50,30.27,fee schedule,,,77.7,,129.76,percent of total billed charges,,,95,,158.65,percent of total billed charges,,,60,,100.2,percent of total billed charges,,100.2,158.65,
Cortisol - LC,30982533,CDM,309,RC,82533,CPT,,,Inpatient,,,167,,,,80,,133.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,129.76,percent of total billed charges,,,95,,158.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,158.65,
"CK, Total+Isoenzymes, Serum LC",30982550,CDM,309,RC,82550,CPT,,,Outpatient,,,60,,,,80,,48,percent of total billed charges,,,,50,11.56,fee schedule,,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,60,,36,percent of total billed charges,,36,57,
"CK, Total+Isoenzymes, Serum LC",30982550,CDM,309,RC,82550,CPT,,,Inpatient,,,60,,,,80,,48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,57,
82552 Isoenzymes,30982552,CDM,309,RC,82552,CPT,,,Outpatient,,,151,,,,80,,120.8,percent of total billed charges,,,,50,24.4,fee schedule,,,77.7,,117.33,percent of total billed charges,,,95,,143.45,percent of total billed charges,,,60,,90.6,percent of total billed charges,,90.6,143.45,
82552 Isoenzymes,30982552,CDM,309,RC,82552,CPT,,,Inpatient,,,151,,,,80,,120.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,117.33,percent of total billed charges,,,95,,143.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,143.45,
82570 Assay of urine creatinine LC,30982570,CDM,309,RC,82570,CPT,,,Outpatient,,,73,,,,80,,58.4,percent of total billed charges,,,,50,10.77,fee schedule,,,77.7,,56.72,percent of total billed charges,,,95,,69.35,percent of total billed charges,,,60,,43.8,percent of total billed charges,,43.8,69.35,
"Creatinine, 24-Hour Urine - LC",30982570,CDM,309,RC,82570,CPT,,,Outpatient,,,73,,,,80,,58.4,percent of total billed charges,,,,50,10.77,fee schedule,,,77.7,,56.72,percent of total billed charges,,,95,,69.35,percent of total billed charges,,,60,,43.8,percent of total billed charges,,43.8,69.35,
82570 Assay of urine creatinine LC,30982570,CDM,309,RC,82570,CPT,,,Inpatient,,,73,,,,80,,58.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,56.72,percent of total billed charges,,,95,,69.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,69.35,
"Creatinine, 24-Hour Urine - LC",30982570,CDM,309,RC,82570,CPT,,,Inpatient,,,73,,,,80,,58.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,56.72,percent of total billed charges,,,95,,69.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,69.35,
Creatinine Clearance - LC,30982575,CDM,309,RC,82575,CPT,,,Outpatient,,,52,,,,80,,41.6,percent of total billed charges,,,,50,17.56,fee schedule,,,77.7,,40.4,percent of total billed charges,,,95,,49.4,percent of total billed charges,,,60,,31.2,percent of total billed charges,,31.2,49.4,
Creatinine Clearance - LC,30982575,CDM,309,RC,82575,CPT,,,Inpatient,,,52,,,,80,,41.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,40.4,percent of total billed charges,,,95,,49.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,49.4,
"Cryoglobulin, Qualitative w/ Quantitative Reflex - LC",30982595,CDM,309,RC,82595,CPT,,,Outpatient,,,53,,,,80,,42.4,percent of total billed charges,,,,50,9.38,fee schedule,,,77.7,,41.18,percent of total billed charges,,,95,,50.35,percent of total billed charges,,,60,,31.8,percent of total billed charges,,31.8,50.35,
"Cryoglobulin, Qualitative w/ Quantitative Reflex - LC",30982595,CDM,309,RC,82595,CPT,,,Inpatient,,,53,,,,80,,42.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,41.18,percent of total billed charges,,,95,,50.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,50.35,
82607 Vitamin B-12 LC,30982607,CDM,309,RC,82607,CPT,,,Outpatient,,,150,,,,80,,120,percent of total billed charges,,,,50,28.71,fee schedule,,,77.7,,116.55,percent of total billed charges,,,95,,142.5,percent of total billed charges,,,60,,90,percent of total billed charges,,90,142.5,
82607 Vitamin B-12 LC,30982607,CDM,309,RC,82607,CPT,,,Inpatient,,,150,,,,80,,120,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,116.55,percent of total billed charges,,,95,,142.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,142.5,
"Cystatin C with Glomerular Filtration Rate, Estimated (eGFR) - LC",30982610,CDM,309,RC,82610,CPT,,,Outpatient,,,199,,,,80,,159.2,percent of total billed charges,,,,50,7.47,fee schedule,,,77.7,,154.62,percent of total billed charges,,,95,,189.05,percent of total billed charges,,,60,,119.4,percent of total billed charges,,119.4,189.05,
"Cystatin C with Glomerular Filtration Rate, Estimated (eGFR) - LC",30982610,CDM,309,RC,82610,CPT,,,Inpatient,,,199,,,,80,,159.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,154.62,percent of total billed charges,,,95,,189.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,189.05,
"DHEA, Serum LC",30982626,CDM,309,RC,82626,CPT,,,Outpatient,,,236,,,,80,,188.8,percent of total billed charges,,,,50,45.76,fee schedule,,,77.7,,183.37,percent of total billed charges,,,95,,224.2,percent of total billed charges,,,60,,141.6,percent of total billed charges,,141.6,224.2,
"DHEA, Serum LC",30982626,CDM,309,RC,82626,CPT,,,Inpatient,,,236,,,,80,,188.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,183.37,percent of total billed charges,,,95,,224.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,224.2,
"Estradiol, Sensitive - LC",30982670,CDM,309,RC,82670,CPT,,,Outpatient,,,335,,,,80,,268,percent of total billed charges,,,,50,62.6,fee schedule,,,77.7,,260.3,percent of total billed charges,,,95,,318.25,percent of total billed charges,,,60,,201,percent of total billed charges,,201,318.25,
"Estradiol, Sensitive - LC",30982670,CDM,309,RC,82670,CPT,,,Inpatient,,,335,,,,80,,268,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,260.3,percent of total billed charges,,,95,,318.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,318.25,
"Estrogens, Total LC",30982672,CDM,309,RC,82672,CPT,,,Outpatient,,,230,,,,80,,184,percent of total billed charges,,,,50,42.26,fee schedule,,,77.7,,178.71,percent of total billed charges,,,95,,218.5,percent of total billed charges,,,60,,138,percent of total billed charges,,138,218.5,
"Estrogens, Total LC",30982672,CDM,309,RC,82672,CPT,,,Inpatient,,,230,,,,80,,184,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,178.71,percent of total billed charges,,,95,,218.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,218.5,
82677 Assay of estriol LC,30982677,CDM,309,RC,82677,CPT,,,Outpatient,,,164,,,,80,,131.2,percent of total billed charges,,,,50,34.77,fee schedule,,,77.7,,127.43,percent of total billed charges,,,95,,155.8,percent of total billed charges,,,60,,98.4,percent of total billed charges,,98.4,155.8,
82677 Assay of estriol LC,30982677,CDM,309,RC,82677,CPT,,,Inpatient,,,164,,,,80,,131.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,127.43,percent of total billed charges,,,95,,155.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,155.8,
"Ethylene Glycol, Serum or Plasma - LC",30982693,CDM,309,RC,82693,CPT,,,Outpatient,,,163,,,,80,,130.4,percent of total billed charges,,,,50,34.2,fee schedule,,,77.7,,126.65,percent of total billed charges,,,95,,154.85,percent of total billed charges,,,60,,97.8,percent of total billed charges,,97.8,154.85,
"Ethylene Glycol, Serum or Plasma - LC",30982693,CDM,309,RC,82693,CPT,,,Inpatient,,,163,,,,80,,130.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,126.65,percent of total billed charges,,,95,,154.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,154.85,
82705 Fecal Fat,30982705,CDM,309,RC,82705,CPT,,,Outpatient,,,47,,,,80,,37.6,percent of total billed charges,,,,50,8.86,fee schedule,,,77.7,,36.52,percent of total billed charges,,,95,,44.65,percent of total billed charges,,,60,,28.2,percent of total billed charges,,28.2,44.65,
82705 Fecal Fat,30982705,CDM,309,RC,82705,CPT,,,Inpatient,,,47,,,,80,,37.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,36.52,percent of total billed charges,,,95,,44.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,44.65,
"Fecal Fat, Quantitative LC",30982710,CDM,309,RC,82710,CPT,,,Outpatient,,,157,,,,80,,125.6,percent of total billed charges,,,,50,31.68,fee schedule,,,77.7,,121.99,percent of total billed charges,,,95,,149.15,percent of total billed charges,,,60,,94.2,percent of total billed charges,,94.2,149.15,
"Fecal Fat, Quantitative LC",30982710,CDM,309,RC,82710,CPT,,,Inpatient,,,157,,,,80,,125.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,121.99,percent of total billed charges,,,95,,149.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,149.15,
"Folate, RBC - LC",30982747,CDM,309,RC,82747,CPT,,,Outpatient,,,174,,,,80,,139.2,percent of total billed charges,,,,50,31.8,fee schedule,,,77.7,,135.2,percent of total billed charges,,,95,,165.3,percent of total billed charges,,,60,,104.4,percent of total billed charges,,104.4,165.3,
"Folate, RBC - LC",30982747,CDM,309,RC,82747,CPT,,,Inpatient,,,174,,,,80,,139.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,135.2,percent of total billed charges,,,95,,165.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,165.3,
82784 ASSAY OF GAMMAGLOBULIN IGA IGD IGG IGM EACH LC,30982784,CDM,309,RC,82784,CPT,,,Outpatient,,,71,,,,80,,56.8,percent of total billed charges,,,,50,24.62,fee schedule,,,77.7,,55.17,percent of total billed charges,,,95,,67.45,percent of total billed charges,,,60,,42.6,percent of total billed charges,,42.6,67.45,
82784 Assay iga/igd/igg/igm each LC,30982784,CDM,309,RC,82784,CPT,,,Outpatient,,,137,,,,80,,109.6,percent of total billed charges,,,,50,24.62,fee schedule,,,77.7,,106.45,percent of total billed charges,,,95,,130.15,percent of total billed charges,,,60,,82.2,percent of total billed charges,,82.2,130.15,
Celiac Ab tTG DGP TIgA LC,30982784,CDM,309,RC,82784,CPT,,,Outpatient,,,80,,,,80,,64,percent of total billed charges,,,,50,24.62,fee schedule,,,77.7,,62.16,percent of total billed charges,,,95,,76,percent of total billed charges,,,60,,48,percent of total billed charges,,48,76,
Celiac Disease Comprehensive - LC,30982784,CDM,309,RC,82784,CPT,,,Outpatient,,,75,,,,80,,60,percent of total billed charges,,,,50,24.62,fee schedule,,,77.7,,58.28,percent of total billed charges,,,95,,71.25,percent of total billed charges,,,60,,45,percent of total billed charges,,45,71.25,
Celiac Disease Panel LC,30982784,CDM,309,RC,82784,CPT,,,Outpatient,,,75,,,,80,,60,percent of total billed charges,,,,50,24.62,fee schedule,,,77.7,,58.28,percent of total billed charges,,,95,,71.25,percent of total billed charges,,,60,,45,percent of total billed charges,,45,71.25,
"Immunoglobulin M, Qn, Serum - LC",30982784,CDM,309,RC,82784,CPT,,,Outpatient,,,137,,,,80,,109.6,percent of total billed charges,,,,50,24.62,fee schedule,,,77.7,,106.45,percent of total billed charges,,,95,,130.15,percent of total billed charges,,,60,,82.2,percent of total billed charges,,82.2,130.15,
"Immunoglobulins A/G/M, Qn, Ser LC",30982784,CDM,309,RC,82784,CPT,,,Outpatient,,,137,,,,80,,109.6,percent of total billed charges,,,,50,24.62,fee schedule,,,77.7,,106.45,percent of total billed charges,,,95,,130.15,percent of total billed charges,,,60,,82.2,percent of total billed charges,,82.2,130.15,
tTG IgA IgG - LC,30982784,CDM,309,RC,82784,CPT,,,Outpatient,,,137,,,,80,,109.6,percent of total billed charges,,,,50,24.62,fee schedule,,,77.7,,106.45,percent of total billed charges,,,95,,130.15,percent of total billed charges,,,60,,82.2,percent of total billed charges,,82.2,130.15,
82784 ASSAY OF GAMMAGLOBULIN IGA IGD IGG IGM EACH LC,30982784,CDM,309,RC,82784,CPT,,,Inpatient,,,71,,,,80,,56.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,55.17,percent of total billed charges,,,95,,67.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,67.45,
82784 Assay iga/igd/igg/igm each LC,30982784,CDM,309,RC,82784,CPT,,,Inpatient,,,137,,,,80,,109.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,106.45,percent of total billed charges,,,95,,130.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,130.15,
Celiac Ab tTG DGP TIgA LC,30982784,CDM,309,RC,82784,CPT,,,Inpatient,,,80,,,,80,,64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,62.16,percent of total billed charges,,,95,,76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,76,
Celiac Disease Comprehensive - LC,30982784,CDM,309,RC,82784,CPT,,,Inpatient,,,75,,,,80,,60,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,58.28,percent of total billed charges,,,95,,71.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,71.25,
Celiac Disease Panel LC,30982784,CDM,309,RC,82784,CPT,,,Inpatient,,,75,,,,80,,60,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,58.28,percent of total billed charges,,,95,,71.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,71.25,
"Immunoglobulin M, Qn, Serum - LC",30982784,CDM,309,RC,82784,CPT,,,Inpatient,,,137,,,,80,,109.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,106.45,percent of total billed charges,,,95,,130.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,130.15,
"Immunoglobulins A/G/M, Qn, Ser LC",30982784,CDM,309,RC,82784,CPT,,,Inpatient,,,137,,,,80,,109.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,106.45,percent of total billed charges,,,95,,130.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,130.15,
tTG IgA IgG - LC,30982784,CDM,309,RC,82784,CPT,,,Inpatient,,,137,,,,80,,109.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,106.45,percent of total billed charges,,,95,,130.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,130.15,
82785 Assay of IGE LC,30982785,CDM,309,RC,82785,CPT,,,Outpatient,,,168,,,,80,,134.4,percent of total billed charges,,,,50,31.64,fee schedule,,,77.7,,130.54,percent of total billed charges,,,95,,159.6,percent of total billed charges,,,60,,100.8,percent of total billed charges,,100.8,159.6,
Allergy Total - RL,30982785,CDM,309,RC,82785,CPT,,,Outpatient,,,165,,,,80,,132,percent of total billed charges,,,,50,31.64,fee schedule,,,77.7,,128.21,percent of total billed charges,,,95,,156.75,percent of total billed charges,,,60,,99,percent of total billed charges,,99,156.75,
82785 Assay of IGE LC,30982785,CDM,309,RC,82785,CPT,,,Inpatient,,,168,,,,80,,134.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,130.54,percent of total billed charges,,,95,,159.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,159.6,
Allergy Total - RL,30982785,CDM,309,RC,82785,CPT,,,Inpatient,,,165,,,,80,,132,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,128.21,percent of total billed charges,,,95,,156.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,156.75,
Gastrin LC,30982941,CDM,309,RC,82941,CPT,,,Outpatient,,,178,,,,80,,142.4,percent of total billed charges,,,,50,34.12,fee schedule,,,77.7,,138.31,percent of total billed charges,,,95,,169.1,percent of total billed charges,,,60,,106.8,percent of total billed charges,,106.8,169.1,
Gastrin LC,30982941,CDM,309,RC,82941,CPT,,,Inpatient,,,178,,,,80,,142.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,138.31,percent of total billed charges,,,95,,169.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,169.1,
"Glucose, Body Fluid LC",30982945,CDM,309,RC,82945,CPT,,,Outpatient,,,60,,,,80,,48,percent of total billed charges,,,,50,7.14,fee schedule,,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,60,,36,percent of total billed charges,,36,57,
"Glucose, Cerebrospinal Fluid LC",30982945,CDM,309,RC,82945,CPT,,,Outpatient,,,60,,,,80,,48,percent of total billed charges,,,,50,7.14,fee schedule,,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,60,,36,percent of total billed charges,,36,57,
"Glucose, Body Fluid LC",30982945,CDM,309,RC,82945,CPT,,,Inpatient,,,60,,,,80,,48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,57,
"Glucose, Cerebrospinal Fluid LC",30982945,CDM,309,RC,82945,CPT,,,Inpatient,,,60,,,,80,,48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,57,
Lactose Tolerance Test - LC,30982951,CDM,309,RC,82951,CPT,,,Outpatient,,,105,,,,80,,84,percent of total billed charges,,,,50,24.36,fee schedule,,,77.7,,81.59,percent of total billed charges,,,95,,99.75,percent of total billed charges,,,60,,63,percent of total billed charges,,63,99.75,
Lactose Tolerance Test - LC,30982951,CDM,309,RC,82951,CPT,,,Inpatient,,,105,,,,80,,84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,81.59,percent of total billed charges,,,95,,99.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,99.75,
82952 GLUCOSE TOLERANCE EA ADDL BEYOND 3 SPECIMENS LC,30982952,CDM,309,RC,82952,CPT,,,Outpatient,,,45,,,,80,,36,percent of total billed charges,,,,50,7.29,fee schedule,,,77.7,,34.97,percent of total billed charges,,,95,,42.75,percent of total billed charges,,,60,,27,percent of total billed charges,,27,42.75,
82952 GLUCOSE TOLERANCE EA ADDL BEYOND 3 SPECIMENS LC,30982952,CDM,309,RC,82952,CPT,,,Inpatient,,,45,,,,80,,36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,34.97,percent of total billed charges,,,95,,42.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,42.75,
"G6PD, Quant, Bld and RBC - LC",30982955,CDM,309,RC,82955,CPT,,,Outpatient,,,116,,,,80,,92.8,percent of total billed charges,,,,50,38.86,fee schedule,,,77.7,,90.13,percent of total billed charges,,,95,,110.2,percent of total billed charges,,,60,,69.6,percent of total billed charges,,69.6,110.2,
"G6PD, Quant, Bld and RBC - LC",30982955,CDM,309,RC,82955,CPT,,,Inpatient,,,116,,,,80,,92.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,90.13,percent of total billed charges,,,95,,110.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,110.2,
Fructosamine - LC,30982985,CDM,309,RC,82985,CPT,,,Outpatient,,,66,,,,80,,52.8,percent of total billed charges,,,,50,20.77,fee schedule,,,77.7,,51.28,percent of total billed charges,,,95,,62.7,percent of total billed charges,,,60,,39.6,percent of total billed charges,,39.6,62.7,
Fructosamine - LC,30982985,CDM,309,RC,82985,CPT,,,Inpatient,,,66,,,,80,,52.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,51.28,percent of total billed charges,,,95,,62.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,62.7,
"FSH, Pediatric LC",30983001,CDM,309,RC,83001,CPT,,,Outpatient,,,194,,,,80,,155.2,percent of total billed charges,,,,50,35.65,fee schedule,,,77.7,,150.74,percent of total billed charges,,,95,,184.3,percent of total billed charges,,,60,,116.4,percent of total billed charges,,116.4,184.3,
"FSH, Pediatric LC",30983001,CDM,309,RC,83001,CPT,,,Inpatient,,,194,,,,80,,155.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,150.74,percent of total billed charges,,,95,,184.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,184.3,
83002 GONADOTROPIN LUTEINIZING HORMONE LC,30983002,CDM,309,RC,83002,CPT,,,Outpatient,,,102,,,,80,,81.6,percent of total billed charges,,,,50,34.78,fee schedule,,,77.7,,79.25,percent of total billed charges,,,95,,96.9,percent of total billed charges,,,60,,61.2,percent of total billed charges,,61.2,96.9,
83002 GONADOTROPIN LUTEINIZING HORMONE LC,30983002,CDM,309,RC,83002,CPT,,,Inpatient,,,102,,,,80,,81.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,79.25,percent of total billed charges,,,95,,96.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,96.9,
Haptoglobin LC,30983010,CDM,309,RC,83010,CPT,,,Outpatient,,,178,,,,80,,142.4,percent of total billed charges,,,,50,26.05,fee schedule,,,77.7,,138.31,percent of total billed charges,,,95,,169.1,percent of total billed charges,,,60,,106.8,percent of total billed charges,,106.8,169.1,
Haptoglobin LC,30983010,CDM,309,RC,83010,CPT,,,Inpatient,,,178,,,,80,,142.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,138.31,percent of total billed charges,,,95,,169.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,169.1,
Helicobacter pylori Urea Breath Test - LC,30983013,CDM,309,RC,83013,CPT,,,Outpatient,,,580,,,,80,,464,percent of total billed charges,,,,50,137.44,fee schedule,,,77.7,,450.66,percent of total billed charges,,,95,,551,percent of total billed charges,,,60,,348,percent of total billed charges,,348,551,
Helicobacter pylori Urea Breath Test - LC,30983013,CDM,309,RC,83013,CPT,,,Inpatient,,,580,,,,80,,464,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,450.66,percent of total billed charges,,,95,,551,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,551,
Hemoglobinopathy Fractionation Cascade - LC,30983020,CDM,309,RC,83020,CPT,,,Outpatient,,,78,,,,80,,62.4,percent of total billed charges,,,,50,26,fee schedule,,,77.7,,60.61,percent of total billed charges,,,95,,74.1,percent of total billed charges,,,60,,46.8,percent of total billed charges,,46.8,74.1,
Hemoglobinopathy Fractionation Cascade - LC,30983020,CDM,309,RC,83020,CPT,,,Inpatient,,,78,,,,80,,62.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,60.61,percent of total billed charges,,,95,,74.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,74.1,
83090 Assay of homocystine LC,30983090,CDM,309,RC,83090,CPT,,,Outpatient,,,453,,,,80,,362.4,percent of total billed charges,,,,50,88.29,fee schedule,,,77.7,,351.98,percent of total billed charges,,,95,,430.35,percent of total billed charges,,,60,,271.8,percent of total billed charges,,271.8,430.35,
83090 Assay of homocystine LC,30983090,CDM,309,RC,83090,CPT,,,Inpatient,,,453,,,,80,,362.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,351.98,percent of total billed charges,,,95,,430.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,430.35,
"5-HIAA,Quant.,24 Hr Urine LC",30983497,CDM,309,RC,83497,CPT,,,Outpatient,,,152,,,,80,,121.6,percent of total billed charges,,,,50,24.08,fee schedule,,,77.7,,118.1,percent of total billed charges,,,95,,144.4,percent of total billed charges,,,60,,91.2,percent of total billed charges,,91.2,144.4,
"5-HIAA,Quant.,24 Hr Urine LC",30983497,CDM,309,RC,83497,CPT,,,Inpatient,,,152,,,,80,,121.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,118.1,percent of total billed charges,,,95,,144.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,144.4,
17-OH Progesterone LCMS - LC,30983498,CDM,309,RC,83498,CPT,,,Outpatient,,,177,,,,80,,141.6,percent of total billed charges,,,,50,43.81,fee schedule,,,77.7,,137.53,percent of total billed charges,,,95,,168.15,percent of total billed charges,,,60,,106.2,percent of total billed charges,,106.2,168.15,
17-OH Progesterone LCMS - LC,30983498,CDM,309,RC,83498,CPT,,,Inpatient,,,177,,,,80,,141.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,137.53,percent of total billed charges,,,95,,168.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,168.15,
83516 Immunoassay nonantibody LC,30983516,CDM,309,RC,83516,CPT,,,Outpatient,,,167,,,,80,,133.6,percent of total billed charges,,,,50,22.67,fee schedule,,,77.7,,129.76,percent of total billed charges,,,95,,158.65,percent of total billed charges,,,60,,100.2,percent of total billed charges,,100.2,158.65,
ANCA Profile - LC,30983516,CDM,309,RC,83516,CPT,,,Outpatient,,,130,,,,80,,104,percent of total billed charges,,,,50,22.67,fee schedule,,,77.7,,101.01,percent of total billed charges,,,95,,123.5,percent of total billed charges,,,60,,78,percent of total billed charges,,78,123.5,
Anti-Mullerian Hormone (AMH) (Endocrine Sciences) - LC,30983516,CDM,309,RC,83516,CPT,,,Outpatient,,,141,,,,80,,112.8,percent of total billed charges,,,,50,22.67,fee schedule,,,77.7,,109.56,percent of total billed charges,,,95,,133.95,percent of total billed charges,,,60,,84.6,percent of total billed charges,,84.6,133.95,
Antiglomular Basement Membrane Abs - LC,30983516,CDM,309,RC,83516,CPT,,,Outpatient,,,167,,,,80,,133.6,percent of total billed charges,,,,50,22.67,fee schedule,,,77.7,,129.76,percent of total billed charges,,,95,,158.65,percent of total billed charges,,,60,,100.2,percent of total billed charges,,100.2,158.65,
"Antiparietal Cell Ab, APCA - LC",30983516,CDM,309,RC,83516,CPT,,,Outpatient,,,44,,,,80,,35.2,percent of total billed charges,,,,50,22.67,fee schedule,,,77.7,,34.19,percent of total billed charges,,,95,,41.8,percent of total billed charges,,,60,,26.4,percent of total billed charges,,26.4,41.8,
Antiproteinase 3 (PR-3) Abs LC,30983516,CDM,309,RC,83516,CPT,,,Outpatient,,,141,,,,80,,112.8,percent of total billed charges,,,,50,22.67,fee schedule,,,77.7,,109.56,percent of total billed charges,,,95,,133.95,percent of total billed charges,,,60,,84.6,percent of total billed charges,,84.6,133.95,
83516 Immunoassay nonantibody LC,30983516,CDM,309,RC,83516,CPT,,,Inpatient,,,167,,,,80,,133.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,129.76,percent of total billed charges,,,95,,158.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,158.65,
ANCA Profile - LC,30983516,CDM,309,RC,83516,CPT,,,Inpatient,,,130,,,,80,,104,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,101.01,percent of total billed charges,,,95,,123.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,123.5,
Anti-Mullerian Hormone (AMH) (Endocrine Sciences) - LC,30983516,CDM,309,RC,83516,CPT,,,Inpatient,,,141,,,,80,,112.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,109.56,percent of total billed charges,,,95,,133.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,133.95,
Antiglomular Basement Membrane Abs - LC,30983516,CDM,309,RC,83516,CPT,,,Inpatient,,,167,,,,80,,133.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,129.76,percent of total billed charges,,,95,,158.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,158.65,
"Antiparietal Cell Ab, APCA - LC",30983516,CDM,309,RC,83516,CPT,,,Inpatient,,,44,,,,80,,35.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,34.19,percent of total billed charges,,,95,,41.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,41.8,
Antiproteinase 3 (PR-3) Abs LC,30983516,CDM,309,RC,83516,CPT,,,Inpatient,,,141,,,,80,,112.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,109.56,percent of total billed charges,,,95,,133.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,133.95,
"AChR Binding Abs, Serum - LC",30983519,CDM,309,RC,83519,CPT,,,Outpatient,,,60,,,,80,,48,percent of total billed charges,,,,50,18.24,fee schedule,,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,60,,36,percent of total billed charges,,36,57,
"Acetylcholine Receptor (AChR) Abs, Complete Profile LC",30983519,CDM,309,RC,83519,CPT,,,Outpatient,,,60,,,,80,,48,percent of total billed charges,,,,50,18.24,fee schedule,,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,60,,36,percent of total billed charges,,36,57,
"AChR Binding Abs, Serum - LC",30983519,CDM,309,RC,83519,CPT,,,Inpatient,,,60,,,,80,,48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,57,
"Acetylcholine Receptor (AChR) Abs, Complete Profile LC",30983519,CDM,309,RC,83519,CPT,,,Inpatient,,,60,,,,80,,48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,57,
83520 Immunoassay quant nos nonab LC,30983520,CDM,309,RC,83520,CPT,,,Outpatient,,,150,,,,80,,120,percent of total billed charges,,,,50,18.24,fee schedule,,,77.7,,116.55,percent of total billed charges,,,95,,142.5,percent of total billed charges,,,60,,90,percent of total billed charges,,90,142.5,
"14.3.3 eta, Rheumatoid Arthritis - LC",30983520,CDM,309,RC,83520,CPT,,,Outpatient,,,305,,,,80,,244,percent of total billed charges,,,,50,18.24,fee schedule,,,77.7,,236.99,percent of total billed charges,,,95,,289.75,percent of total billed charges,,,60,,183,percent of total billed charges,,183,289.75,
Anti-MPO Antibodies - LC,30983520,CDM,309,RC,83520,CPT,,,Outpatient,,,190,,,,80,,152,percent of total billed charges,,,,50,18.24,fee schedule,,,77.7,,147.63,percent of total billed charges,,,95,,180.5,percent of total billed charges,,,60,,114,percent of total billed charges,,114,180.5,
Factor VIII Antigen - LC,30983520,CDM,309,RC,83520,CPT,,,Outpatient,,,65,,,,80,,52,percent of total billed charges,,,,50,18.24,fee schedule,,,77.7,,50.51,percent of total billed charges,,,95,,61.75,percent of total billed charges,,,60,,39,percent of total billed charges,,39,61.75,
Human Antimouse Antibodies - LC,30983520,CDM,309,RC,83520,CPT,,,Outpatient,,,55,,,,80,,44,percent of total billed charges,,,,50,18.24,fee schedule,,,77.7,,42.74,percent of total billed charges,,,95,,52.25,percent of total billed charges,,,60,,33,percent of total billed charges,,33,52.25,
Preeclampsia Risk Evaluation 2nd-3rd Trimester - LC,30983520,CDM,309,RC,83520,CPT,,,Outpatient,,,150,,,,80,,120,percent of total billed charges,,,,50,18.24,fee schedule,,,77.7,,116.55,percent of total billed charges,,,95,,142.5,percent of total billed charges,,,60,,90,percent of total billed charges,,90,142.5,
"Thyrotropin Receptor Ab, Serum LC",30983520,CDM,309,RC,83520,CPT,,,Outpatient,,,75,,,,80,,60,percent of total billed charges,,,,50,18.24,fee schedule,,,77.7,,58.28,percent of total billed charges,,,95,,71.25,percent of total billed charges,,,60,,45,percent of total billed charges,,45,71.25,
Tryptase LC,30983520,CDM,309,RC,83520,CPT,,,Outpatient,,,98,,,,80,,78.4,percent of total billed charges,,,,50,18.24,fee schedule,,,77.7,,76.15,percent of total billed charges,,,95,,93.1,percent of total billed charges,,,60,,58.8,percent of total billed charges,,58.8,93.1,
83520 Immunoassay quant nos nonab LC,30983520,CDM,309,RC,83520,CPT,,,Inpatient,,,150,,,,80,,120,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,116.55,percent of total billed charges,,,95,,142.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,142.5,
"14.3.3 eta, Rheumatoid Arthritis - LC",30983520,CDM,309,RC,83520,CPT,,,Inpatient,,,305,,,,80,,244,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,236.99,percent of total billed charges,,,95,,289.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,289.75,
Anti-MPO Antibodies - LC,30983520,CDM,309,RC,83520,CPT,,,Inpatient,,,190,,,,80,,152,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,147.63,percent of total billed charges,,,95,,180.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,180.5,
Factor VIII Antigen - LC,30983520,CDM,309,RC,83520,CPT,,,Inpatient,,,65,,,,80,,52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,50.51,percent of total billed charges,,,95,,61.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,61.75,
Human Antimouse Antibodies - LC,30983520,CDM,309,RC,83520,CPT,,,Inpatient,,,55,,,,80,,44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,42.74,percent of total billed charges,,,95,,52.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,52.25,
Preeclampsia Risk Evaluation 2nd-3rd Trimester - LC,30983520,CDM,309,RC,83520,CPT,,,Inpatient,,,150,,,,80,,120,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,116.55,percent of total billed charges,,,95,,142.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,142.5,
"Thyrotropin Receptor Ab, Serum LC",30983520,CDM,309,RC,83520,CPT,,,Inpatient,,,75,,,,80,,60,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,58.28,percent of total billed charges,,,95,,71.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,71.25,
Tryptase LC,30983520,CDM,309,RC,83520,CPT,,,Inpatient,,,98,,,,80,,78.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,76.15,percent of total billed charges,,,95,,93.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,93.1,
83521 IMMUNOGLOBULIN LIGHT CHAINS FREE EACH LC,30983521,CDM,309,RC,83521,CPT,,,Outpatient,,,50,,,,80,,40,percent of total billed charges,,,,50,16.2,fee schedule,,,77.7,,38.85,percent of total billed charges,,,95,,47.5,percent of total billed charges,,,60,,30,percent of total billed charges,,30,47.5,
"Free K+L Lt Chains,Qn,S LC",30983521,CDM,309,RC,83521,CPT,,,Outpatient,,,40,,,,80,,32,percent of total billed charges,,,,50,16.2,fee schedule,,,77.7,,31.08,percent of total billed charges,,,95,,38,percent of total billed charges,,,60,,24,percent of total billed charges,,24,38,
83521 IMMUNOGLOBULIN LIGHT CHAINS FREE EACH LC,30983521,CDM,309,RC,83521,CPT,,,Inpatient,,,50,,,,80,,40,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,38.85,percent of total billed charges,,,95,,47.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,47.5,
"Free K+L Lt Chains,Qn,S LC",30983521,CDM,309,RC,83521,CPT,,,Inpatient,,,40,,,,80,,32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,31.08,percent of total billed charges,,,95,,38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,38,
83525 ASSAY OF INSULIN TOTAL LC,30983525,CDM,309,RC,83525,CPT,,,Outpatient,,,125,,,,80,,100,percent of total billed charges,,,,50,25.36,fee schedule,,,77.7,,97.13,percent of total billed charges,,,95,,118.75,percent of total billed charges,,,60,,75,percent of total billed charges,,75,118.75,
83525 ASSAY OF INSULIN TOTAL LC,30983525,CDM,309,RC,83525,CPT,,,Inpatient,,,125,,,,80,,100,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,97.13,percent of total billed charges,,,95,,118.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,118.75,
"LD, Body Fluid LC",30983615,CDM,309,RC,83615,CPT,,,Outpatient,,,60,,,,80,,48,percent of total billed charges,,,,50,11.39,fee schedule,,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,60,,36,percent of total billed charges,,36,57,
"LD, Body Fluid LC",30983615,CDM,309,RC,83615,CPT,,,Inpatient,,,60,,,,80,,48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,57,
"Lead, Blood (Adult) - LC",30983655,CDM,309,RC,83655,CPT,,,Outpatient,,,63,,,,80,,50.4,percent of total billed charges,,,,50,12.18,fee schedule,,,77.7,,48.95,percent of total billed charges,,,95,,59.85,percent of total billed charges,,,60,,37.8,percent of total billed charges,,37.8,59.85,
"Lead, Blood (Pediatric) LC",30983655,CDM,309,RC,83655,CPT,,,Outpatient,,,63,,,,80,,50.4,percent of total billed charges,,,,50,12.18,fee schedule,,,77.7,,48.95,percent of total billed charges,,,95,,59.85,percent of total billed charges,,,60,,37.8,percent of total billed charges,,37.8,59.85,
"Lead, Blood (Adult) - LC",30983655,CDM,309,RC,83655,CPT,,,Inpatient,,,63,,,,80,,50.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,48.95,percent of total billed charges,,,95,,59.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,59.85,
"Lead, Blood (Pediatric) LC",30983655,CDM,309,RC,83655,CPT,,,Inpatient,,,63,,,,80,,50.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,48.95,percent of total billed charges,,,95,,59.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,59.85,
Lipoprotein (a) LC,30983695,CDM,309,RC,83695,CPT,,,Outpatient,,,40,,,,80,,32,percent of total billed charges,,,,50,14.4,fee schedule,,,77.7,,31.08,percent of total billed charges,,,95,,38,percent of total billed charges,,,60,,24,percent of total billed charges,,24,38,
Lipoprotein (a) LC,30983695,CDM,309,RC,83695,CPT,,,Inpatient,,,40,,,,80,,32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,31.08,percent of total billed charges,,,95,,38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,38,
"Iodine, Serum or Plasma - LC",30983789,CDM,309,RC,83789,CPT,,,Outpatient,,,275,,,,80,,220,percent of total billed charges,,,,50,92.91,fee schedule,,,77.7,,213.68,percent of total billed charges,,,95,,261.25,percent of total billed charges,,,60,,165,percent of total billed charges,,165,261.25,
"Iodine, Serum or Plasma - LC",30983789,CDM,309,RC,83789,CPT,,,Inpatient,,,275,,,,80,,220,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,213.68,percent of total billed charges,,,95,,261.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,261.25,
83825 Assay of mercury LC,30983825,CDM,309,RC,83825,CPT,,,Outpatient,,,204,,,,80,,163.2,percent of total billed charges,,,,50,24.87,fee schedule,,,77.7,,158.51,percent of total billed charges,,,95,,193.8,percent of total billed charges,,,60,,122.4,percent of total billed charges,,122.4,193.8,
83825 Assay of mercury LC,30983825,CDM,309,RC,83825,CPT,,,Inpatient,,,204,,,,80,,163.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,158.51,percent of total billed charges,,,95,,193.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,193.8,
Myoglobin LC,30983874,CDM,309,RC,83874,CPT,,,Outpatient,,,127,,,,80,,101.6,percent of total billed charges,,,,50,23.83,fee schedule,,,77.7,,98.68,percent of total billed charges,,,95,,120.65,percent of total billed charges,,,60,,76.2,percent of total billed charges,,76.2,120.65,
Myoglobin LC,30983874,CDM,309,RC,83874,CPT,,,Inpatient,,,127,,,,80,,101.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,98.68,percent of total billed charges,,,95,,120.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,120.65,
"Alpha-2 Macroglobulins, Qn LC",30983883,CDM,309,RC,83883,CPT,,,Outpatient,,,85,,,,80,,68,percent of total billed charges,,,,50,24.82,fee schedule,,,77.7,,66.05,percent of total billed charges,,,95,,80.75,percent of total billed charges,,,60,,51,percent of total billed charges,,51,80.75,
"Alpha-2 Macroglobulins, Qn LC",30983883,CDM,309,RC,83883,CPT,,,Inpatient,,,85,,,,80,,68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,66.05,percent of total billed charges,,,95,,80.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,80.75,
PTH Intact w/ Calcium - LC,30983970,CDM,309,RC,83970,CPT,,,Outpatient,,,416,,,,80,,332.8,percent of total billed charges,,,,50,77.51,fee schedule,,,77.7,,323.23,percent of total billed charges,,,95,,395.2,percent of total billed charges,,,60,,249.6,percent of total billed charges,,249.6,395.2,
PTH Intact w/ Calcium - LC,30983970,CDM,309,RC,83970,CPT,,,Inpatient,,,416,,,,80,,332.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,323.23,percent of total billed charges,,,95,,395.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,395.2,
Alk Phos Isoenzyme LC,30984075,CDM,309,RC,84075,CPT,,,Outpatient,,,57,,,,80,,45.6,percent of total billed charges,,,,50,5.56,fee schedule,,,77.7,,44.29,percent of total billed charges,,,95,,54.15,percent of total billed charges,,,60,,34.2,percent of total billed charges,,34.2,54.15,
Alk Phos Isoenzyme LC,30984075,CDM,309,RC,84075,CPT,,,Inpatient,,,57,,,,80,,45.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,44.29,percent of total billed charges,,,95,,54.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,54.15,
Free + Total PSA - LC,30984153,CDM,309,RC,84153,CPT,,,Outpatient,,,178,,,,80,,142.4,percent of total billed charges,,,,50,33.98,fee schedule,,,77.7,,138.31,percent of total billed charges,,,95,,169.1,percent of total billed charges,,,60,,106.8,percent of total billed charges,,106.8,169.1,
PSA Total+% Free LC,30984153,CDM,309,RC,84153,CPT,,,Outpatient,,,178,,,,80,,142.4,percent of total billed charges,,,,50,33.98,fee schedule,,,77.7,,138.31,percent of total billed charges,,,95,,169.1,percent of total billed charges,,,60,,106.8,percent of total billed charges,,106.8,169.1,
"Prostate-specific Antigen (PSA), Ultrasensitive - LC",30984153,CDM,309,RC,84153,CPT,,,Outpatient,,,178,,,,80,,142.4,percent of total billed charges,,,,50,33.98,fee schedule,,,77.7,,138.31,percent of total billed charges,,,95,,169.1,percent of total billed charges,,,60,,106.8,percent of total billed charges,,106.8,169.1,
Free + Total PSA - LC,30984153,CDM,309,RC,84153,CPT,,,Inpatient,,,178,,,,80,,142.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,138.31,percent of total billed charges,,,95,,169.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,169.1,
PSA Total+% Free LC,30984153,CDM,309,RC,84153,CPT,,,Inpatient,,,178,,,,80,,142.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,138.31,percent of total billed charges,,,95,,169.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,169.1,
"Prostate-specific Antigen (PSA), Ultrasensitive - LC",30984153,CDM,309,RC,84153,CPT,,,Inpatient,,,178,,,,80,,142.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,138.31,percent of total billed charges,,,95,,169.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,169.1,
84154 ASSAY OF PROSTATE SPECIFIC ANTIGEN FREE LC,30984154,CDM,309,RC,84154,CPT,,,Outpatient,,,152,,,,80,,121.6,percent of total billed charges,,,,50,26.45,fee schedule,,,77.7,,118.1,percent of total billed charges,,,95,,144.4,percent of total billed charges,,,60,,91.2,percent of total billed charges,,91.2,144.4,
84154 ASSAY OF PROSTATE SPECIFIC ANTIGEN FREE LC,30984154,CDM,309,RC,84154,CPT,,,Inpatient,,,152,,,,80,,121.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,118.1,percent of total billed charges,,,95,,144.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,144.4,
84155 Assay of protein serum LC,30984155,CDM,309,RC,84155,CPT,,,Outpatient,,,60,,,,80,,48,percent of total billed charges,,,,50,4.32,fee schedule,,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,60,,36,percent of total billed charges,,36,57,
84155 PROTEIN XCPT REFRACTOMETRY SERUM PLASMA/WHL BLD LC,30984155,CDM,309,RC,84155,CPT,,,Outpatient,,,17,,,,80,,13.6,percent of total billed charges,,,,50,4.32,fee schedule,,,77.7,,13.21,percent of total billed charges,,,95,,16.15,percent of total billed charges,,,60,,10.2,percent of total billed charges,,10.2,16.15,
84155 Assay of protein serum LC,30984155,CDM,309,RC,84155,CPT,,,Inpatient,,,60,,,,80,,48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,57,
84155 PROTEIN XCPT REFRACTOMETRY SERUM PLASMA/WHL BLD LC,30984155,CDM,309,RC,84155,CPT,,,Inpatient,,,17,,,,80,,13.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,13.21,percent of total billed charges,,,95,,16.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,16.15,
84156 Assay of protein urine LC,30984156,CDM,309,RC,84156,CPT,,,Outpatient,,,44,,,,80,,35.2,percent of total billed charges,,,,50,9.41,fee schedule,,,77.7,,34.19,percent of total billed charges,,,95,,41.8,percent of total billed charges,,,60,,26.4,percent of total billed charges,,26.4,41.8,
"Protein Total, Qn, 24-Hr Urine - LC",30984156,CDM,309,RC,84156,CPT,,,Outpatient,,,44,,,,80,,35.2,percent of total billed charges,,,,50,9.41,fee schedule,,,77.7,,34.19,percent of total billed charges,,,95,,41.8,percent of total billed charges,,,60,,26.4,percent of total billed charges,,26.4,41.8,
84156 Assay of protein urine LC,30984156,CDM,309,RC,84156,CPT,,,Inpatient,,,44,,,,80,,35.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,34.19,percent of total billed charges,,,95,,41.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,41.8,
"Protein Total, Qn, 24-Hr Urine - LC",30984156,CDM,309,RC,84156,CPT,,,Inpatient,,,44,,,,80,,35.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,34.19,percent of total billed charges,,,95,,41.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,41.8,
"Protein, Body Fluid LC",30984157,CDM,309,RC,84157,CPT,,,Outpatient,,,60,,,,80,,48,percent of total billed charges,,,,50,9.41,fee schedule,,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,60,,36,percent of total billed charges,,36,57,
"Protein, Total, CSF LC",30984157,CDM,309,RC,84157,CPT,,,Outpatient,,,44,,,,80,,35.2,percent of total billed charges,,,,50,9.41,fee schedule,,,77.7,,34.19,percent of total billed charges,,,95,,41.8,percent of total billed charges,,,60,,26.4,percent of total billed charges,,26.4,41.8,
"Protein, Body Fluid LC",30984157,CDM,309,RC,84157,CPT,,,Inpatient,,,60,,,,80,,48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,57,
"Protein, Total, CSF LC",30984157,CDM,309,RC,84157,CPT,,,Inpatient,,,44,,,,80,,35.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,34.19,percent of total billed charges,,,95,,41.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,41.8,
84165 PROTEIN ELECTROPHORETIC FRACTJ&QUANTJ SERUM LC,30984165,CDM,309,RC,84165,CPT,,,Outpatient,,,61,,,,80,,48.8,percent of total billed charges,,,,50,20.15,fee schedule,,,77.7,,47.4,percent of total billed charges,,,95,,57.95,percent of total billed charges,,,60,,36.6,percent of total billed charges,,36.6,57.95,
84165 Protein e-phoresis serum LC,30984165,CDM,309,RC,84165,CPT,,,Outpatient,,,114,,,,80,,91.2,percent of total billed charges,,,,50,20.15,fee schedule,,,77.7,,88.58,percent of total billed charges,,,95,,108.3,percent of total billed charges,,,60,,68.4,percent of total billed charges,,68.4,108.3,
Protein Elec and Interp - LC,30984165,CDM,309,RC,84165,CPT,,,Outpatient,,,110,,,,80,,88,percent of total billed charges,,,,50,20.15,fee schedule,,,77.7,,85.47,percent of total billed charges,,,95,,104.5,percent of total billed charges,,,60,,66,percent of total billed charges,,66,104.5,
"Protein Electrophoresis, Serum w/ Reflex to IFE - LC",30984165,CDM,309,RC,84165,CPT,,,Outpatient,,,110,,,,80,,88,percent of total billed charges,,,,50,20.15,fee schedule,,,77.7,,85.47,percent of total billed charges,,,95,,104.5,percent of total billed charges,,,60,,66,percent of total billed charges,,66,104.5,
84165 PROTEIN ELECTROPHORETIC FRACTJ&QUANTJ SERUM LC,30984165,CDM,309,RC,84165,CPT,,,Inpatient,,,61,,,,80,,48.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,47.4,percent of total billed charges,,,95,,57.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,57.95,
84165 Protein e-phoresis serum LC,30984165,CDM,309,RC,84165,CPT,,,Inpatient,,,114,,,,80,,91.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,88.58,percent of total billed charges,,,95,,108.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,108.3,
Protein Elec and Interp - LC,30984165,CDM,309,RC,84165,CPT,,,Inpatient,,,110,,,,80,,88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,85.47,percent of total billed charges,,,95,,104.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,104.5,
"Protein Electrophoresis, Serum w/ Reflex to IFE - LC",30984165,CDM,309,RC,84165,CPT,,,Inpatient,,,110,,,,80,,88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,85.47,percent of total billed charges,,,95,,104.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,104.5,
84244 ASSAY OF RENIN,30984244,CDM,309,RC,84244,CPT,,,Outpatient,,,120,,,,80,,96,percent of total billed charges,,,,50,40.19,fee schedule,,,77.7,,93.24,percent of total billed charges,,,95,,114,percent of total billed charges,,,60,,72,percent of total billed charges,,72,114,
"Renin Activity, Plasma - LC",30984244,CDM,309,RC,84244,CPT,,,Outpatient,,,199,,,,80,,159.2,percent of total billed charges,,,,50,40.19,fee schedule,,,77.7,,154.62,percent of total billed charges,,,95,,189.05,percent of total billed charges,,,60,,119.4,percent of total billed charges,,119.4,189.05,
84244 ASSAY OF RENIN,30984244,CDM,309,RC,84244,CPT,,,Inpatient,,,120,,,,80,,96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,93.24,percent of total billed charges,,,95,,114,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,114,
"Renin Activity, Plasma - LC",30984244,CDM,309,RC,84244,CPT,,,Inpatient,,,199,,,,80,,159.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,154.62,percent of total billed charges,,,95,,189.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,189.05,
"Sex Horm Binding Glob, Serum - LC",30984270,CDM,309,RC,84270,CPT,,,Outpatient,,,349,,,,80,,279.2,percent of total billed charges,,,,50,64.43,fee schedule,,,77.7,,271.17,percent of total billed charges,,,95,,331.55,percent of total billed charges,,,60,,209.4,percent of total billed charges,,209.4,331.55,
"Sex Horm Binding Glob, Serum - LC",30984270,CDM,309,RC,84270,CPT,,,Inpatient,,,349,,,,80,,279.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,271.17,percent of total billed charges,,,95,,331.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,331.55,
"Sodium, 24-Hour Urine - LC",30984300,CDM,309,RC,84300,CPT,,,Outpatient,,,57,,,,80,,45.6,percent of total billed charges,,,,50,9.77,fee schedule,,,77.7,,44.29,percent of total billed charges,,,95,,54.15,percent of total billed charges,,,60,,34.2,percent of total billed charges,,34.2,54.15,
"Sodium, 24-Hour Urine - LC",30984300,CDM,309,RC,84300,CPT,,,Inpatient,,,57,,,,80,,45.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,44.29,percent of total billed charges,,,95,,54.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,54.15,
"Insulin-like Growth Factor 1(IGF-!), Ped. w/ Z Score - LC",30984305,CDM,309,RC,84305,CPT,,,Outpatient,,,302,,,,80,,241.6,percent of total billed charges,,,,50,60.37,fee schedule,,,77.7,,234.65,percent of total billed charges,,,95,,286.9,percent of total billed charges,,,60,,181.2,percent of total billed charges,,181.2,286.9,
"Insulin-like Growth Factor 1(IGF-!), Ped. w/ Z Score - LC",30984305,CDM,309,RC,84305,CPT,,,Inpatient,,,302,,,,80,,241.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,234.65,percent of total billed charges,,,95,,286.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,286.9,
"Testosterone, Free+Total LC/MS LC",30984402,CDM,309,RC,84402,CPT,,,Outpatient,,,295,,,,80,,236,percent of total billed charges,,,,50,54.33,fee schedule,,,77.7,,229.22,percent of total billed charges,,,95,,280.25,percent of total billed charges,,,60,,177,percent of total billed charges,,177,280.25,
"Testosterone,Free and Total LC",30984402,CDM,309,RC,84402,CPT,,,Outpatient,,,295,,,,80,,236,percent of total billed charges,,,,50,54.33,fee schedule,,,77.7,,229.22,percent of total billed charges,,,95,,280.25,percent of total billed charges,,,60,,177,percent of total billed charges,,177,280.25,
"Testosterone, Free+Total LC/MS LC",30984402,CDM,309,RC,84402,CPT,,,Inpatient,,,295,,,,80,,236,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,229.22,percent of total billed charges,,,95,,280.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,280.25,
"Testosterone,Free and Total LC",30984402,CDM,309,RC,84402,CPT,,,Inpatient,,,295,,,,80,,236,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,229.22,percent of total billed charges,,,95,,280.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,280.25,
84403 Assay of total testosterone LC,30984403,CDM,309,RC,84403,CPT,,,Outpatient,,,284,,,,80,,227.2,percent of total billed charges,,,,50,52.43,fee schedule,,,77.7,,220.67,percent of total billed charges,,,95,,269.8,percent of total billed charges,,,60,,170.4,percent of total billed charges,,170.4,269.8,
"Testosterone, Serum LC",30984403,CDM,309,RC,84403,CPT,,,Outpatient,,,284,,,,80,,227.2,percent of total billed charges,,,,50,52.43,fee schedule,,,77.7,,220.67,percent of total billed charges,,,95,,269.8,percent of total billed charges,,,60,,170.4,percent of total billed charges,,170.4,269.8,
84403 Assay of total testosterone LC,30984403,CDM,309,RC,84403,CPT,,,Inpatient,,,284,,,,80,,227.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,220.67,percent of total billed charges,,,95,,269.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,269.8,
"Testosterone, Serum LC",30984403,CDM,309,RC,84403,CPT,,,Inpatient,,,284,,,,80,,227.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,220.67,percent of total billed charges,,,95,,269.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,269.8,
Comprehensive Thyroglobulin - LC,30984432,CDM,309,RC,84432,CPT,,,Outpatient,,,74,,,,80,,59.2,percent of total billed charges,,,,50,44.45,fee schedule,,,77.7,,57.5,percent of total billed charges,,,95,,70.3,percent of total billed charges,,,60,,44.4,percent of total billed charges,,44.4,70.3,
Comprehensive Thyroglobulin - LC,30984432,CDM,309,RC,84432,CPT,,,Inpatient,,,74,,,,80,,59.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,57.5,percent of total billed charges,,,95,,70.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,70.3,
Thyroxine (T4) LC,30984436,CDM,309,RC,84436,CPT,,,Outpatient,,,49,,,,80,,39.2,percent of total billed charges,,,,50,8.98,fee schedule,,,77.7,,38.07,percent of total billed charges,,,95,,46.55,percent of total billed charges,,,60,,29.4,percent of total billed charges,,29.4,46.55,
Thyroxine (T4) LC,30984436,CDM,309,RC,84436,CPT,,,Inpatient,,,49,,,,80,,39.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,38.07,percent of total billed charges,,,95,,46.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,46.55,
84443 Assay thyroid stim hormone LC,30984443,CDM,309,RC,84443,CPT,,,Outpatient,,,145,,,,80,,116,percent of total billed charges,,,,50,21.99,fee schedule,,,77.7,,112.67,percent of total billed charges,,,95,,137.75,percent of total billed charges,,,60,,87,percent of total billed charges,,87,137.75,
84443 Assay thyroid stim hormone LC,30984443,CDM,309,RC,84443,CPT,,,Inpatient,,,145,,,,80,,116,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,112.67,percent of total billed charges,,,95,,137.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,137.75,
Thyroid Stim Immunoglobulin - LC,30984445,CDM,309,RC,84445,CPT,,,Outpatient,,,1200,,,,80,,960,percent of total billed charges,,,,50,234.93,fee schedule,,,77.7,,932.4,percent of total billed charges,,,95,,1140,percent of total billed charges,,,60,,720,percent of total billed charges,,720,1140,
Thyroid Stim Immunoglobulin - LC,30984445,CDM,309,RC,84445,CPT,,,Inpatient,,,1200,,,,80,,960,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,932.4,percent of total billed charges,,,95,,1140,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1140,
"Vitamin E, Serum LC",30984446,CDM,309,RC,84446,CPT,,,Outpatient,,,150,,,,80,,120,percent of total billed charges,,,,50,28.12,fee schedule,,,77.7,,116.55,percent of total billed charges,,,95,,142.5,percent of total billed charges,,,60,,90,percent of total billed charges,,90,142.5,
"Vitamin E, Serum LC",30984446,CDM,309,RC,84446,CPT,,,Inpatient,,,150,,,,80,,120,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,116.55,percent of total billed charges,,,95,,142.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,142.5,
"Uric Acid, 24 hr Urine LC",30984560,CDM,309,RC,84560,CPT,,,Outpatient,,,32.68,,,,80,,26.14,percent of total billed charges,,,,50,10.2,fee schedule,,,77.7,,25.39,percent of total billed charges,,,95,,31.05,percent of total billed charges,,,60,,19.61,percent of total billed charges,,19.61,31.05,
"Uric Acid, 24 hr Urine LC",30984560,CDM,309,RC,84560,CPT,,,Inpatient,,,32.68,,,,80,,26.14,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,25.39,percent of total billed charges,,,95,,31.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,31.05,
84585 VMA 24hr Urine,30984585,CDM,309,RC,84585,CPT,,,Outpatient,,,168,,,,80,,134.4,percent of total billed charges,,,,50,30.48,fee schedule,,,77.7,,130.54,percent of total billed charges,,,95,,159.6,percent of total billed charges,,,60,,100.8,percent of total billed charges,,100.8,159.6,
84585 VMA 24hr Urine,30984585,CDM,309,RC,84585,CPT,,,Inpatient,,,168,,,,80,,134.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,130.54,percent of total billed charges,,,95,,159.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,159.6,
Antidiuretic Hormone (ADH) - LC,30984588,CDM,309,RC,84588,CPT,,,Outpatient,,,185,,,,80,,148,percent of total billed charges,,,,50,64.25,fee schedule,,,77.7,,143.75,percent of total billed charges,,,95,,175.75,percent of total billed charges,,,60,,111,percent of total billed charges,,111,175.75,
Antidiuretic Hormone (ADH) - LC,30984588,CDM,309,RC,84588,CPT,,,Inpatient,,,185,,,,80,,148,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,143.75,percent of total billed charges,,,95,,175.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,175.75,
"Zinc, Plasma or Serum LC",30984630,CDM,309,RC,84630,CPT,,,Outpatient,,,65,,,,80,,52,percent of total billed charges,,,,50,14.43,fee schedule,,,77.7,,50.51,percent of total billed charges,,,95,,61.75,percent of total billed charges,,,60,,39,percent of total billed charges,,39,61.75,
"Zinc, Plasma or Serum LC",30984630,CDM,309,RC,84630,CPT,,,Inpatient,,,65,,,,80,,52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,50.51,percent of total billed charges,,,95,,61.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,61.75,
"Insulin and C-Peptide, Serum LC",30984681,CDM,309,RC,84681,CPT,,,Outpatient,,,150,,,,80,,120,percent of total billed charges,,,,50,33.32,fee schedule,,,77.7,,116.55,percent of total billed charges,,,95,,142.5,percent of total billed charges,,,60,,90,percent of total billed charges,,90,142.5,
"Insulin and C-Peptide, Serum LC",30984681,CDM,309,RC,84681,CPT,,,Inpatient,,,150,,,,80,,120,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,116.55,percent of total billed charges,,,95,,142.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,142.5,
85041 Automated RBC count LC,30985041,CDM,309,RC,85041,CPT,,,Outpatient,,,30,,,,80,,24,percent of total billed charges,,,,50,5.31,fee schedule,,,77.7,,23.31,percent of total billed charges,,,95,,28.5,percent of total billed charges,,,60,,18,percent of total billed charges,,18,28.5,
85041 Automated RBC count LC,30985041,CDM,309,RC,85041,CPT,,,Inpatient,,,30,,,,80,,24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,23.31,percent of total billed charges,,,95,,28.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,28.5,
"Hematopath Consultation, Smear - LC",30985060,CDM,309,RC,85060,CPT,,,Outpatient,,,125,,,,80,,100,percent of total billed charges,,,,50,39.49,fee schedule,,,77.7,,97.13,percent of total billed charges,,,95,,118.75,percent of total billed charges,,,60,,75,percent of total billed charges,,75,118.75,
"Hematopath Consultation, Smear - LC",30985060,CDM,309,RC,85060,CPT,,,Inpatient,,,125,,,,80,,100,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,97.13,percent of total billed charges,,,95,,118.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,118.75,
Factor V Activity - LC,30985220,CDM,309,RC,85220,CPT,,,Outpatient,,,227,,,,80,,181.6,percent of total billed charges,,,,50,32.86,fee schedule,,,77.7,,176.38,percent of total billed charges,,,95,,215.65,percent of total billed charges,,,60,,136.2,percent of total billed charges,,136.2,215.65,
Factor V Activity - LC,30985220,CDM,309,RC,85220,CPT,,,Inpatient,,,227,,,,80,,181.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,176.38,percent of total billed charges,,,95,,215.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,215.65,
85240 Clot factor viii ahg 1 stage LC,30985240,CDM,309,RC,85240,CPT,,,Outpatient,,,250,,,,80,,200,percent of total billed charges,,,,50,44.24,fee schedule,,,77.7,,194.25,percent of total billed charges,,,95,,237.5,percent of total billed charges,,,60,,150,percent of total billed charges,,150,237.5,
Factor VIII Activity - LC,30985240,CDM,309,RC,85240,CPT,,,Outpatient,,,250,,,,80,,200,percent of total billed charges,,,,50,44.24,fee schedule,,,77.7,,194.25,percent of total billed charges,,,95,,237.5,percent of total billed charges,,,60,,150,percent of total billed charges,,150,237.5,
85240 Clot factor viii ahg 1 stage LC,30985240,CDM,309,RC,85240,CPT,,,Inpatient,,,250,,,,80,,200,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,194.25,percent of total billed charges,,,95,,237.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,237.5,
Factor VIII Activity - LC,30985240,CDM,309,RC,85240,CPT,,,Inpatient,,,250,,,,80,,200,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,194.25,percent of total billed charges,,,95,,237.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,237.5,
Factor X Activity - LC,30985260,CDM,309,RC,85260,CPT,,,Outpatient,,,96,,,,80,,76.8,percent of total billed charges,,,,50,33.09,fee schedule,,,77.7,,74.59,percent of total billed charges,,,95,,91.2,percent of total billed charges,,,60,,57.6,percent of total billed charges,,57.6,91.2,
Factor X Activity - LC,30985260,CDM,309,RC,85260,CPT,,,Inpatient,,,96,,,,80,,76.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,74.59,percent of total billed charges,,,95,,91.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,91.2,
Antithrombin Activity LC,30985300,CDM,309,RC,85300,CPT,,,Outpatient,,,84,,,,80,,67.2,percent of total billed charges,,,,50,21.49,fee schedule,,,77.7,,65.27,percent of total billed charges,,,95,,79.8,percent of total billed charges,,,60,,50.4,percent of total billed charges,,50.4,79.8,
"Antithrombin III, Func/Immunol LC",30985300,CDM,309,RC,85300,CPT,,,Outpatient,,,84,,,,80,,67.2,percent of total billed charges,,,,50,21.49,fee schedule,,,77.7,,65.27,percent of total billed charges,,,95,,79.8,percent of total billed charges,,,60,,50.4,percent of total billed charges,,50.4,79.8,
Antithrombin Activity LC,30985300,CDM,309,RC,85300,CPT,,,Inpatient,,,84,,,,80,,67.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,65.27,percent of total billed charges,,,95,,79.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,79.8,
"Antithrombin III, Func/Immunol LC",30985300,CDM,309,RC,85300,CPT,,,Inpatient,,,84,,,,80,,67.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,65.27,percent of total billed charges,,,95,,79.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,79.8,
85302 Clot inhibit prot C antigen LC,30985302,CDM,309,RC,85302,CPT,,,Outpatient,,,48,,,,80,,38.4,percent of total billed charges,,,,50,15.31,fee schedule,,,77.7,,37.3,percent of total billed charges,,,95,,45.6,percent of total billed charges,,,60,,28.8,percent of total billed charges,,28.8,45.6,
85302 Clot inhibit prot C antigen LC,30985302,CDM,309,RC,85302,CPT,,,Inpatient,,,48,,,,80,,38.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,37.3,percent of total billed charges,,,95,,45.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,45.6,
Protein C Deficiency Profile - LC,30985303,CDM,309,RC,85303,CPT,,,Outpatient,,,129,,,,80,,103.2,percent of total billed charges,,,,50,42.85,fee schedule,,,77.7,,100.23,percent of total billed charges,,,95,,122.55,percent of total billed charges,,,60,,77.4,percent of total billed charges,,77.4,122.55,
Protein C Deficiency Profile - LC,30985303,CDM,309,RC,85303,CPT,,,Inpatient,,,129,,,,80,,103.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,100.23,percent of total billed charges,,,95,,122.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,122.55,
Protein S-Functional LC,30985306,CDM,309,RC,85306,CPT,,,Outpatient,,,257,,,,80,,205.6,percent of total billed charges,,,,50,54.13,fee schedule,,,77.7,,199.69,percent of total billed charges,,,95,,244.15,percent of total billed charges,,,60,,154.2,percent of total billed charges,,154.2,244.15,
Protein S-Functional LC,30985306,CDM,309,RC,85306,CPT,,,Inpatient,,,257,,,,80,,205.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,199.69,percent of total billed charges,,,95,,244.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,244.15,
Fibrinogen Antigen LC,30985385,CDM,309,RC,85385,CPT,,,Outpatient,,,67,,,,80,,53.6,percent of total billed charges,,,,50,18.21,fee schedule,,,77.7,,52.06,percent of total billed charges,,,95,,63.65,percent of total billed charges,,,60,,40.2,percent of total billed charges,,40.2,63.65,
Fibrinogen Antigen LC,30985385,CDM,309,RC,85385,CPT,,,Inpatient,,,67,,,,80,,53.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,52.06,percent of total billed charges,,,95,,63.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,63.65,
85613 Russell viper venom diluted LC,30985613,CDM,309,RC,85613,CPT,,,Outpatient,,,236,,,,80,,188.8,percent of total billed charges,,,,50,13.52,fee schedule,,,77.7,,183.37,percent of total billed charges,,,95,,224.2,percent of total billed charges,,,60,,141.6,percent of total billed charges,,141.6,224.2,
Lupus Anticoagulant Reflex LC,30985613,CDM,309,RC,85613,CPT,,,Outpatient,,,236,,,,80,,188.8,percent of total billed charges,,,,50,13.52,fee schedule,,,77.7,,183.37,percent of total billed charges,,,95,,224.2,percent of total billed charges,,,60,,141.6,percent of total billed charges,,141.6,224.2,
85613 Russell viper venom diluted LC,30985613,CDM,309,RC,85613,CPT,,,Inpatient,,,236,,,,80,,188.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,183.37,percent of total billed charges,,,95,,224.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,224.2,
Lupus Anticoagulant Reflex LC,30985613,CDM,309,RC,85613,CPT,,,Inpatient,,,236,,,,80,,188.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,183.37,percent of total billed charges,,,95,,224.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,224.2,
Hemoglobin Solubility - LC,30985660,CDM,309,RC,85660,CPT,,,Outpatient,,,54,,,,80,,43.2,percent of total billed charges,,,,50,7.17,fee schedule,,,77.7,,41.96,percent of total billed charges,,,95,,51.3,percent of total billed charges,,,60,,32.4,percent of total billed charges,,32.4,51.3,
Hemoglobin Solubility - LC,30985660,CDM,309,RC,85660,CPT,,,Inpatient,,,54,,,,80,,43.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,41.96,percent of total billed charges,,,95,,51.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,51.3,
85670 Thrombin time plasma LC,30985670,CDM,309,RC,85670,CPT,,,Outpatient,,,85,,,,80,,68,percent of total billed charges,,,,50,15.18,fee schedule,,,77.7,,66.05,percent of total billed charges,,,95,,80.75,percent of total billed charges,,,60,,51,percent of total billed charges,,51,80.75,
85670 Thrombin time plasma LC,30985670,CDM,309,RC,85670,CPT,,,Inpatient,,,85,,,,80,,68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,66.05,percent of total billed charges,,,95,,80.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,80.75,
85705 Thromboplastin inhibition LC,30985705,CDM,309,RC,85705,CPT,,,Outpatient,,,229,,,,80,,183.2,percent of total billed charges,,,,50,48.17,fee schedule,,,77.7,,177.93,percent of total billed charges,,,95,,217.55,percent of total billed charges,,,60,,137.4,percent of total billed charges,,137.4,217.55,
85705 Thromboplastin inhibition LC,30985705,CDM,309,RC,85705,CPT,,,Inpatient,,,229,,,,80,,183.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,177.93,percent of total billed charges,,,95,,217.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,217.55,
85732 Thromboplastin time partial LC,30985732,CDM,309,RC,85732,CPT,,,Outpatient,,,46,,,,80,,36.8,percent of total billed charges,,,,50,11.56,fee schedule,,,77.7,,35.74,percent of total billed charges,,,95,,43.7,percent of total billed charges,,,60,,27.6,percent of total billed charges,,27.6,43.7,
85732 Thromboplastin time partial LC,30985732,CDM,309,RC,85732,CPT,,,Inpatient,,,46,,,,80,,36.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,35.74,percent of total billed charges,,,95,,43.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,43.7,
86003 Allg spec ige crude xtrc ea LC,30986003,CDM,309,RC,86003,CPT,,,Outpatient,,,25,,,,80,,20,percent of total billed charges,,,,50,7.76,fee schedule,,,77.7,,19.43,percent of total billed charges,,,95,,23.75,percent of total billed charges,,,60,,15,percent of total billed charges,,15,23.75,
Allergen Specific IgE - RL,30986003,CDM,309,RC,86003,CPT,,,Outpatient,,,25,,,,80,,20,percent of total billed charges,,,,50,7.76,fee schedule,,,77.7,,19.43,percent of total billed charges,,,95,,23.75,percent of total billed charges,,,60,,15,percent of total billed charges,,15,23.75,
86003 Allg spec ige crude xtrc ea LC,30986003,CDM,309,RC,86003,CPT,,,Inpatient,,,25,,,,80,,20,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.43,percent of total billed charges,,,95,,23.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,23.75,
Allergen Specific IgE - RL,30986003,CDM,309,RC,86003,CPT,,,Inpatient,,,25,,,,80,,20,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,19.43,percent of total billed charges,,,95,,23.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,23.75,
Allergy IgE Microscreen - RL,30986005,CDM,309,RC,86005,CPT,,,Outpatient,,,80,,,,80,,64,percent of total billed charges,,,,50,24.81,fee schedule,,,77.7,,62.16,percent of total billed charges,,,95,,76,percent of total billed charges,,,60,,48,percent of total billed charges,,48,76,
Allergy IgE Microscreen - RL,30986005,CDM,309,RC,86005,CPT,,,Inpatient,,,80,,,,80,,64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,62.16,percent of total billed charges,,,95,,76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,76,
86008 Allg spec ige recomb ea LC,30986008,CDM,309,RC,86008,CPT,,,Outpatient,,,67,,,,80,,53.6,percent of total billed charges,,,,50,20.13,fee schedule,,,77.7,,52.06,percent of total billed charges,,,95,,63.65,percent of total billed charges,,,60,,40.2,percent of total billed charges,,40.2,63.65,
86008 Allg spec ige recomb ea LC,30986008,CDM,309,RC,86008,CPT,,,Inpatient,,,67,,,,80,,53.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,52.06,percent of total billed charges,,,95,,63.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,63.65,
86015 ACTIN SMOOTH MUSCLE ANTIBODY EACH LC,30986015,CDM,309,RC,86015,CPT,,,Outpatient,,,160,,,,80,,128,percent of total billed charges,,,,50,10.81,fee schedule,,,77.7,,124.32,percent of total billed charges,,,95,,152,percent of total billed charges,,,60,,96,percent of total billed charges,,96,152,
86015 ACTIN SMOOTH MUSCLE ANTIBODY EACH LC,30986015,CDM,309,RC,86015,CPT,,,Inpatient,,,160,,,,80,,128,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,124.32,percent of total billed charges,,,95,,152,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,152,
86037 Antineutrophil Cytoplasmic Antb Titer Ea Antb,30986037,CDM,309,RC,86037,CPT,,,Outpatient,,,65,,,,80,,52,percent of total billed charges,,,,50,18.44,fee schedule,,,77.7,,50.51,percent of total billed charges,,,95,,61.75,percent of total billed charges,,,60,,39,percent of total billed charges,,39,61.75,
IBD Profile - LC,30986037,CDM,309,RC,86037,CPT,,,Outpatient,,,62,,,,80,,49.6,percent of total billed charges,,,,50,18.44,fee schedule,,,77.7,,48.17,percent of total billed charges,,,95,,58.9,percent of total billed charges,,,60,,37.2,percent of total billed charges,,37.2,58.9,
86037 Antineutrophil Cytoplasmic Antb Titer Ea Antb,30986037,CDM,309,RC,86037,CPT,,,Inpatient,,,65,,,,80,,52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,50.51,percent of total billed charges,,,95,,61.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,61.75,
IBD Profile - LC,30986037,CDM,309,RC,86037,CPT,,,Inpatient,,,62,,,,80,,49.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,48.17,percent of total billed charges,,,95,,58.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,58.9,
86038 ANTINUCLEAR ANTIBODIES ANA LC,30986038,CDM,309,RC,86038,CPT,,,Outpatient,,,116,,,,80,,92.8,percent of total billed charges,,,,50,22.15,fee schedule,,,77.7,,90.13,percent of total billed charges,,,95,,110.2,percent of total billed charges,,,60,,69.6,percent of total billed charges,,69.6,110.2,
"ANA 12 Profile, Do All (RDL) - LC",30986038,CDM,309,RC,86038,CPT,,,Outpatient,,,116,,,,80,,92.8,percent of total billed charges,,,,50,22.15,fee schedule,,,77.7,,90.13,percent of total billed charges,,,95,,110.2,percent of total billed charges,,,60,,69.6,percent of total billed charges,,69.6,110.2,
ANA Direct - LC,30986038,CDM,309,RC,86038,CPT,,,Outpatient,,,116,,,,80,,92.8,percent of total billed charges,,,,50,22.15,fee schedule,,,77.7,,90.13,percent of total billed charges,,,95,,110.2,percent of total billed charges,,,60,,69.6,percent of total billed charges,,69.6,110.2,
"Antinuclear Antibodies, IFA LC",30986038,CDM,309,RC,86038,CPT,,,Outpatient,,,116,,,,80,,92.8,percent of total billed charges,,,,50,22.15,fee schedule,,,77.7,,90.13,percent of total billed charges,,,95,,110.2,percent of total billed charges,,,60,,69.6,percent of total billed charges,,69.6,110.2,
86038 ANTINUCLEAR ANTIBODIES ANA LC,30986038,CDM,309,RC,86038,CPT,,,Inpatient,,,116,,,,80,,92.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,90.13,percent of total billed charges,,,95,,110.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,110.2,
"ANA 12 Profile, Do All (RDL) - LC",30986038,CDM,309,RC,86038,CPT,,,Inpatient,,,116,,,,80,,92.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,90.13,percent of total billed charges,,,95,,110.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,110.2,
ANA Direct - LC,30986038,CDM,309,RC,86038,CPT,,,Inpatient,,,116,,,,80,,92.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,90.13,percent of total billed charges,,,95,,110.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,110.2,
"Antinuclear Antibodies, IFA LC",30986038,CDM,309,RC,86038,CPT,,,Inpatient,,,116,,,,80,,92.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,90.13,percent of total billed charges,,,95,,110.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,110.2,
"C-Reactive Protein, High Sensitivity, Cardiac - LC",30986141,CDM,309,RC,86141,CPT,,,Outpatient,,,163,,,,80,,130.4,percent of total billed charges,,,,50,30.64,fee schedule,,,77.7,,126.65,percent of total billed charges,,,95,,154.85,percent of total billed charges,,,60,,97.8,percent of total billed charges,,97.8,154.85,
"C-Reactive Protein, High Sensitivity, Cardiac - LC",30986141,CDM,309,RC,86141,CPT,,,Inpatient,,,163,,,,80,,130.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,126.65,percent of total billed charges,,,95,,154.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,154.85,
86146 Beta-2 glycoprotein antibody LC,30986146,CDM,309,RC,86146,CPT,,,Outpatient,,,94,,,,80,,75.2,percent of total billed charges,,,,50,28.39,fee schedule,,,77.7,,73.04,percent of total billed charges,,,95,,89.3,percent of total billed charges,,,60,,56.4,percent of total billed charges,,56.4,89.3,
"Beta-2 Glycoprotein I Ab, G,A,M - LC",30986146,CDM,309,RC,86146,CPT,,,Outpatient,,,94,,,,80,,75.2,percent of total billed charges,,,,50,28.39,fee schedule,,,77.7,,73.04,percent of total billed charges,,,95,,89.3,percent of total billed charges,,,60,,56.4,percent of total billed charges,,56.4,89.3,
"Beta-2 Glycoprotein I Ab, IgG - LC",30986146,CDM,309,RC,86146,CPT,,,Outpatient,,,94,,,,80,,75.2,percent of total billed charges,,,,50,28.39,fee schedule,,,77.7,,73.04,percent of total billed charges,,,95,,89.3,percent of total billed charges,,,60,,56.4,percent of total billed charges,,56.4,89.3,
"Beta-2 Glycoprotein I Ab, IgM - LC",30986146,CDM,309,RC,86146,CPT,,,Outpatient,,,94,,,,80,,75.2,percent of total billed charges,,,,50,28.39,fee schedule,,,77.7,,73.04,percent of total billed charges,,,95,,89.3,percent of total billed charges,,,60,,56.4,percent of total billed charges,,56.4,89.3,
86146 Beta-2 glycoprotein antibody LC,30986146,CDM,309,RC,86146,CPT,,,Inpatient,,,94,,,,80,,75.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,73.04,percent of total billed charges,,,95,,89.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,89.3,
"Beta-2 Glycoprotein I Ab, G,A,M - LC",30986146,CDM,309,RC,86146,CPT,,,Inpatient,,,94,,,,80,,75.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,73.04,percent of total billed charges,,,95,,89.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,89.3,
"Beta-2 Glycoprotein I Ab, IgG - LC",30986146,CDM,309,RC,86146,CPT,,,Inpatient,,,94,,,,80,,75.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,73.04,percent of total billed charges,,,95,,89.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,89.3,
"Beta-2 Glycoprotein I Ab, IgM - LC",30986146,CDM,309,RC,86146,CPT,,,Inpatient,,,94,,,,80,,75.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,73.04,percent of total billed charges,,,95,,89.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,89.3,
86147 Cardiolipin antibody ea ig LC,30986147,CDM,309,RC,86147,CPT,,,Outpatient,,,137,,,,80,,109.6,percent of total billed charges,,,,50,39.21,fee schedule,,,77.7,,106.45,percent of total billed charges,,,95,,130.15,percent of total billed charges,,,60,,82.2,percent of total billed charges,,82.2,130.15,
Anticardiolipin IgG - LC,30986147,CDM,309,RC,86147,CPT,,,Outpatient,,,137,,,,80,,109.6,percent of total billed charges,,,,50,39.21,fee schedule,,,77.7,,106.45,percent of total billed charges,,,95,,130.15,percent of total billed charges,,,60,,82.2,percent of total billed charges,,82.2,130.15,
86147 Cardiolipin antibody ea ig LC,30986147,CDM,309,RC,86147,CPT,,,Inpatient,,,137,,,,80,,109.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,106.45,percent of total billed charges,,,95,,130.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,130.15,
Anticardiolipin IgG - LC,30986147,CDM,309,RC,86147,CPT,,,Inpatient,,,137,,,,80,,109.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,106.45,percent of total billed charges,,,95,,130.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,130.15,
86148 Antiphosphatidylserine/Prothrombin Antibody,30986148,CDM,309,RC,86148,CPT,,,Outpatient,,,294,,,,80,,235.2,percent of total billed charges,,,,50,24.53,fee schedule,,,77.7,,228.44,percent of total billed charges,,,95,,279.3,percent of total billed charges,,,60,,176.4,percent of total billed charges,,176.4,279.3,
"Anti-PS/PT Abs IgG, IgM - LC",30986148,CDM,309,RC,86148,CPT,,,Outpatient,,,294,,,,80,,235.2,percent of total billed charges,,,,50,24.53,fee schedule,,,77.7,,228.44,percent of total billed charges,,,95,,279.3,percent of total billed charges,,,60,,176.4,percent of total billed charges,,176.4,279.3,
86148 Antiphosphatidylserine/Prothrombin Antibody,30986148,CDM,309,RC,86148,CPT,,,Inpatient,,,294,,,,80,,235.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,228.44,percent of total billed charges,,,95,,279.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,279.3,
"Anti-PS/PT Abs IgG, IgM - LC",30986148,CDM,309,RC,86148,CPT,,,Inpatient,,,294,,,,80,,235.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,228.44,percent of total billed charges,,,95,,279.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,279.3,
"Cold Agglutinin Titer, Quant LC",30986157,CDM,309,RC,86157,CPT,,,Outpatient,,,87,,,,80,,69.6,percent of total billed charges,,,,50,15.44,fee schedule,,,77.7,,67.6,percent of total billed charges,,,95,,82.65,percent of total billed charges,,,60,,52.2,percent of total billed charges,,52.2,82.65,
"Cold Agglutinin Titer, Quant LC",30986157,CDM,309,RC,86157,CPT,,,Inpatient,,,87,,,,80,,69.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,67.6,percent of total billed charges,,,95,,82.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,82.65,
86160 Complement Antigen,30986160,CDM,309,RC,86160,CPT,,,Outpatient,,,152,,,,80,,121.6,percent of total billed charges,,,,50,27.84,fee schedule,,,77.7,,118.1,percent of total billed charges,,,95,,144.4,percent of total billed charges,,,60,,91.2,percent of total billed charges,,91.2,144.4,
"C1 Esterase Inhibitor, Serum LC",30986160,CDM,309,RC,86160,CPT,,,Outpatient,,,152,,,,80,,121.6,percent of total billed charges,,,,50,27.84,fee schedule,,,77.7,,118.1,percent of total billed charges,,,95,,144.4,percent of total billed charges,,,60,,91.2,percent of total billed charges,,91.2,144.4,
86160 Complement Antigen,30986160,CDM,309,RC,86160,CPT,,,Inpatient,,,152,,,,80,,121.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,118.1,percent of total billed charges,,,95,,144.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,144.4,
"C1 Esterase Inhibitor, Serum LC",30986160,CDM,309,RC,86160,CPT,,,Inpatient,,,152,,,,80,,121.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,118.1,percent of total billed charges,,,95,,144.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,144.4,
"Complement, Total (CH50) LC",30986162,CDM,309,RC,86162,CPT,,,Outpatient,,,216,,,,80,,172.8,percent of total billed charges,,,,50,39.7,fee schedule,,,77.7,,167.83,percent of total billed charges,,,95,,205.2,percent of total billed charges,,,60,,129.6,percent of total billed charges,,129.6,205.2,
"Complement, Total (CH50) LC",30986162,CDM,309,RC,86162,CPT,,,Inpatient,,,216,,,,80,,172.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,167.83,percent of total billed charges,,,95,,205.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,205.2,
86225 DNA antibody native LC,30986225,CDM,309,RC,86225,CPT,,,Outpatient,,,168,,,,80,,134.4,percent of total billed charges,,,,50,30.38,fee schedule,,,77.7,,130.54,percent of total billed charges,,,95,,159.6,percent of total billed charges,,,60,,100.8,percent of total billed charges,,100.8,159.6,
ANA Comprehensive Panel - LC,30986225,CDM,309,RC,86225,CPT,,,Outpatient,,,168,,,,80,,134.4,percent of total billed charges,,,,50,30.38,fee schedule,,,77.7,,130.54,percent of total billed charges,,,95,,159.6,percent of total billed charges,,,60,,100.8,percent of total billed charges,,100.8,159.6,
dsDNA (nDNA) Scrn by Crithidia - LC,30986225,CDM,309,RC,86225,CPT,,,Outpatient,,,82,,,,80,,65.6,percent of total billed charges,,,,50,30.38,fee schedule,,,77.7,,63.71,percent of total billed charges,,,95,,77.9,percent of total billed charges,,,60,,49.2,percent of total billed charges,,49.2,77.9,
86225 DNA antibody native LC,30986225,CDM,309,RC,86225,CPT,,,Inpatient,,,168,,,,80,,134.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,130.54,percent of total billed charges,,,95,,159.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,159.6,
ANA Comprehensive Panel - LC,30986225,CDM,309,RC,86225,CPT,,,Inpatient,,,168,,,,80,,134.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,130.54,percent of total billed charges,,,95,,159.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,159.6,
dsDNA (nDNA) Scrn by Crithidia - LC,30986225,CDM,309,RC,86225,CPT,,,Inpatient,,,82,,,,80,,65.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,63.71,percent of total billed charges,,,95,,77.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.9,
86231 EMA each IG class LC,30986231,CDM,309,RC,86231,CPT,,,Outpatient,,,75,,,,80,,60,percent of total billed charges,,,,50,11.34,fee schedule,,,77.7,,58.28,percent of total billed charges,,,95,,71.25,percent of total billed charges,,,60,,45,percent of total billed charges,,45,71.25,
86231 ENDOMYSIAL ANTIBODY EACH IMMUNOGLOBULIN CLASS LC,30986231,CDM,309,RC,86231,CPT,,,Outpatient,,,30,,,,80,,24,percent of total billed charges,,,,50,11.34,fee schedule,,,77.7,,23.31,percent of total billed charges,,,95,,28.5,percent of total billed charges,,,60,,18,percent of total billed charges,,18,28.5,
Endomysial Antibody IgA - LC,30986231,CDM,309,RC,86231,CPT,,,Outpatient,,,30,,,,80,,24,percent of total billed charges,,,,50,11.34,fee schedule,,,77.7,,23.31,percent of total billed charges,,,95,,28.5,percent of total billed charges,,,60,,18,percent of total billed charges,,18,28.5,
86231 EMA each IG class LC,30986231,CDM,309,RC,86231,CPT,,,Inpatient,,,75,,,,80,,60,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,58.28,percent of total billed charges,,,95,,71.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,71.25,
86231 ENDOMYSIAL ANTIBODY EACH IMMUNOGLOBULIN CLASS LC,30986231,CDM,309,RC,86231,CPT,,,Inpatient,,,30,,,,80,,24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,23.31,percent of total billed charges,,,95,,28.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,28.5,
Endomysial Antibody IgA - LC,30986231,CDM,309,RC,86231,CPT,,,Inpatient,,,30,,,,80,,24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,23.31,percent of total billed charges,,,95,,28.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,28.5,
86235 Nuclear Antigen Antibody,30986235,CDM,309,RC,86235,CPT,,,Outpatient,,,160,,,,80,,128,percent of total billed charges,,,,50,26.13,fee schedule,,,77.7,,124.32,percent of total billed charges,,,95,,152,percent of total billed charges,,,60,,96,percent of total billed charges,,96,152,
Anti-Jo-1 - LC,30986235,CDM,309,RC,86235,CPT,,,Outpatient,,,132,,,,80,,105.6,percent of total billed charges,,,,50,26.13,fee schedule,,,77.7,,102.56,percent of total billed charges,,,95,,125.4,percent of total billed charges,,,60,,79.2,percent of total billed charges,,79.2,125.4,
Anti-Sm Ab - LC,30986235,CDM,309,RC,86235,CPT,,,Outpatient,,,157,,,,80,,125.6,percent of total billed charges,,,,50,26.13,fee schedule,,,77.7,,121.99,percent of total billed charges,,,95,,149.15,percent of total billed charges,,,60,,94.2,percent of total billed charges,,94.2,149.15,
Antichromatin Antibodies - LC,30986235,CDM,309,RC,86235,CPT,,,Outpatient,,,132,,,,80,,105.6,percent of total billed charges,,,,50,26.13,fee schedule,,,77.7,,102.56,percent of total billed charges,,,95,,125.4,percent of total billed charges,,,60,,79.2,percent of total billed charges,,79.2,125.4,
Antiextractable Nuclear Ag - LC,30986235,CDM,309,RC,86235,CPT,,,Outpatient,,,132,,,,80,,105.6,percent of total billed charges,,,,50,26.13,fee schedule,,,77.7,,102.56,percent of total billed charges,,,95,,125.4,percent of total billed charges,,,60,,79.2,percent of total billed charges,,79.2,125.4,
Antihistone Antibodies - LC,30986235,CDM,309,RC,86235,CPT,,,Outpatient,,,157,,,,80,,125.6,percent of total billed charges,,,,50,26.13,fee schedule,,,77.7,,121.99,percent of total billed charges,,,95,,149.15,percent of total billed charges,,,60,,94.2,percent of total billed charges,,94.2,149.15,
Antiscleroderma 70 Abs - LC,30986235,CDM,309,RC,86235,CPT,,,Outpatient,,,132,,,,80,,105.6,percent of total billed charges,,,,50,26.13,fee schedule,,,77.7,,102.56,percent of total billed charges,,,95,,125.4,percent of total billed charges,,,60,,79.2,percent of total billed charges,,79.2,125.4,
"Sjogren's Ab, Anti-SS-A/SS-B - LC",30986235,CDM,309,RC,86235,CPT,,,Outpatient,,,70,,,,80,,56,percent of total billed charges,,,,50,26.13,fee schedule,,,77.7,,54.39,percent of total billed charges,,,95,,66.5,percent of total billed charges,,,60,,42,percent of total billed charges,,42,66.5,
Smith Antibodies - LC,30986235,CDM,309,RC,86235,CPT,,,Outpatient,,,157,,,,80,,125.6,percent of total billed charges,,,,50,26.13,fee schedule,,,77.7,,121.99,percent of total billed charges,,,95,,149.15,percent of total billed charges,,,60,,94.2,percent of total billed charges,,94.2,149.15,
Smith/RNP Antibodies - LC,30986235,CDM,309,RC,86235,CPT,,,Outpatient,,,71,,,,80,,56.8,percent of total billed charges,,,,50,26.13,fee schedule,,,77.7,,55.17,percent of total billed charges,,,95,,67.45,percent of total billed charges,,,60,,42.6,percent of total billed charges,,42.6,67.45,
86235 Nuclear Antigen Antibody,30986235,CDM,309,RC,86235,CPT,,,Inpatient,,,160,,,,80,,128,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,124.32,percent of total billed charges,,,95,,152,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,152,
Anti-Jo-1 - LC,30986235,CDM,309,RC,86235,CPT,,,Inpatient,,,132,,,,80,,105.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,102.56,percent of total billed charges,,,95,,125.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,125.4,
Anti-Sm Ab - LC,30986235,CDM,309,RC,86235,CPT,,,Inpatient,,,157,,,,80,,125.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,121.99,percent of total billed charges,,,95,,149.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,149.15,
Antichromatin Antibodies - LC,30986235,CDM,309,RC,86235,CPT,,,Inpatient,,,132,,,,80,,105.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,102.56,percent of total billed charges,,,95,,125.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,125.4,
Antiextractable Nuclear Ag - LC,30986235,CDM,309,RC,86235,CPT,,,Inpatient,,,132,,,,80,,105.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,102.56,percent of total billed charges,,,95,,125.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,125.4,
Antihistone Antibodies - LC,30986235,CDM,309,RC,86235,CPT,,,Inpatient,,,157,,,,80,,125.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,121.99,percent of total billed charges,,,95,,149.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,149.15,
Antiscleroderma 70 Abs - LC,30986235,CDM,309,RC,86235,CPT,,,Inpatient,,,132,,,,80,,105.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,102.56,percent of total billed charges,,,95,,125.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,125.4,
"Sjogren's Ab, Anti-SS-A/SS-B - LC",30986235,CDM,309,RC,86235,CPT,,,Inpatient,,,70,,,,80,,56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,54.39,percent of total billed charges,,,95,,66.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,66.5,
Smith Antibodies - LC,30986235,CDM,309,RC,86235,CPT,,,Inpatient,,,157,,,,80,,125.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,121.99,percent of total billed charges,,,95,,149.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,149.15,
Smith/RNP Antibodies - LC,30986235,CDM,309,RC,86235,CPT,,,Inpatient,,,71,,,,80,,56.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,55.17,percent of total billed charges,,,95,,67.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,67.45,
ANA+ENA+C3+C4+RA Qn+DNA/DS+... LC,30986255,CDM,309,RC,86255,CPT,,,Outpatient,,,278,,,,80,,222.4,percent of total billed charges,,,,50,24.99,fee schedule,,,77.7,,216.01,percent of total billed charges,,,95,,264.1,percent of total billed charges,,,60,,166.8,percent of total billed charges,,166.8,264.1,
"Anti-Hu, Ri, Yo Ab Profile - LC",30986255,CDM,309,RC,86255,CPT,,,Outpatient,,,110,,,,80,,88,percent of total billed charges,,,,50,24.99,fee schedule,,,77.7,,85.47,percent of total billed charges,,,95,,104.5,percent of total billed charges,,,60,,66,percent of total billed charges,,66,104.5,
"Antiskin Autoantibodies, Quant - LC",30986255,CDM,309,RC,86255,CPT,,,Outpatient,,,95,,,,80,,76,percent of total billed charges,,,,50,24.99,fee schedule,,,77.7,,73.82,percent of total billed charges,,,95,,90.25,percent of total billed charges,,,60,,57,percent of total billed charges,,57,90.25,
ANA+ENA+C3+C4+RA Qn+DNA/DS+... LC,30986255,CDM,309,RC,86255,CPT,,,Inpatient,,,278,,,,80,,222.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,216.01,percent of total billed charges,,,95,,264.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,264.1,
"Anti-Hu, Ri, Yo Ab Profile - LC",30986255,CDM,309,RC,86255,CPT,,,Inpatient,,,110,,,,80,,88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,85.47,percent of total billed charges,,,95,,104.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,104.5,
"Antiskin Autoantibodies, Quant - LC",30986255,CDM,309,RC,86255,CPT,,,Inpatient,,,95,,,,80,,76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,73.82,percent of total billed charges,,,95,,90.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,90.25,
86256 Fluorescent Antibody Titer,30986256,CDM,309,RC,86256,CPT,,,Outpatient,,,109,,,,80,,87.2,percent of total billed charges,,,,50,28.53,fee schedule,,,77.7,,84.69,percent of total billed charges,,,95,,103.55,percent of total billed charges,,,60,,65.4,percent of total billed charges,,65.4,103.55,
86256 Fluorescent Antibody Titer,30986256,CDM,309,RC,86256,CPT,,,Inpatient,,,109,,,,80,,87.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,84.69,percent of total billed charges,,,95,,103.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,103.55,
86258 DGP antibody each IG class LC,30986258,CDM,309,RC,86258,CPT,,,Outpatient,,,45,,,,80,,36,percent of total billed charges,,,,50,11.69,fee schedule,,,77.7,,34.97,percent of total billed charges,,,95,,42.75,percent of total billed charges,,,60,,27,percent of total billed charges,,27,42.75,
86258 GLIADIN ANTIBODY EACH IMMUNOGLOBULIN CLASS LC,30986258,CDM,309,RC,86258,CPT,,,Outpatient,,,35,,,,80,,28,percent of total billed charges,,,,50,11.69,fee schedule,,,77.7,,27.2,percent of total billed charges,,,95,,33.25,percent of total billed charges,,,60,,21,percent of total billed charges,,21,33.25,
"Gliadin IgG/IgA Ab Prof, EIA - LC",30986258,CDM,309,RC,86258,CPT,,,Outpatient,,,35,,,,80,,28,percent of total billed charges,,,,50,11.69,fee schedule,,,77.7,,27.2,percent of total billed charges,,,95,,33.25,percent of total billed charges,,,60,,21,percent of total billed charges,,21,33.25,
86258 DGP antibody each IG class LC,30986258,CDM,309,RC,86258,CPT,,,Inpatient,,,45,,,,80,,36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,34.97,percent of total billed charges,,,95,,42.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,42.75,
86258 GLIADIN ANTIBODY EACH IMMUNOGLOBULIN CLASS LC,30986258,CDM,309,RC,86258,CPT,,,Inpatient,,,35,,,,80,,28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,27.2,percent of total billed charges,,,95,,33.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,33.25,
"Gliadin IgG/IgA Ab Prof, EIA - LC",30986258,CDM,309,RC,86258,CPT,,,Inpatient,,,35,,,,80,,28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,27.2,percent of total billed charges,,,95,,33.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,33.25,
Cancer Antigen (CA) 15-3 LC,30986300,CDM,309,RC,86300,CPT,,,Outpatient,,,227,,,,80,,181.6,percent of total billed charges,,,,50,27.42,fee schedule,,,77.7,,176.38,percent of total billed charges,,,95,,215.65,percent of total billed charges,,,60,,136.2,percent of total billed charges,,136.2,215.65,
Cancer Antigen (CA) 15-3 LC,30986300,CDM,309,RC,86300,CPT,,,Inpatient,,,227,,,,80,,181.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,176.38,percent of total billed charges,,,95,,215.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,215.65,
Chromogranin A - LC,30986316,CDM,309,RC,86316,CPT,,,Outpatient,,,122,,,,80,,97.6,percent of total billed charges,,,,50,27.25,fee schedule,,,77.7,,94.79,percent of total billed charges,,,95,,115.9,percent of total billed charges,,,60,,73.2,percent of total billed charges,,73.2,115.9,
Chromogranin A - LC,30986316,CDM,309,RC,86316,CPT,,,Inpatient,,,122,,,,80,,97.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,94.79,percent of total billed charges,,,95,,115.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,115.9,
Hepatitis B Surf Ab Quant - LC,30986317,CDM,309,RC,86317,CPT,,,Outpatient,,,135,,,,80,,108,percent of total billed charges,,,,50,22.28,fee schedule,,,77.7,,104.9,percent of total billed charges,,,95,,128.25,percent of total billed charges,,,60,,81,percent of total billed charges,,81,128.25,
Hepatitis B Surf Ab Quant - LC,30986317,CDM,309,RC,86317,CPT,,,Inpatient,,,135,,,,80,,108,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,104.9,percent of total billed charges,,,95,,128.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,128.25,
"IFE and PE, Serum LC",30986334,CDM,309,RC,86334,CPT,,,Outpatient,,,135,,,,80,,108,percent of total billed charges,,,,50,48.53,fee schedule,,,77.7,,104.9,percent of total billed charges,,,95,,128.25,percent of total billed charges,,,60,,81,percent of total billed charges,,81,128.25,
"IFE, PE and FLC, Serum LC",30986334,CDM,309,RC,86334,CPT,,,Outpatient,,,140,,,,80,,112,percent of total billed charges,,,,50,48.53,fee schedule,,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,60,,84,percent of total billed charges,,84,133,
"Immunofixation, Serum LC",30986334,CDM,309,RC,86334,CPT,,,Outpatient,,,200,,,,80,,160,percent of total billed charges,,,,50,48.53,fee schedule,,,77.7,,155.4,percent of total billed charges,,,95,,190,percent of total billed charges,,,60,,120,percent of total billed charges,,120,190,
"IFE and PE, Serum LC",30986334,CDM,309,RC,86334,CPT,,,Inpatient,,,135,,,,80,,108,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,104.9,percent of total billed charges,,,95,,128.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,128.25,
"IFE, PE and FLC, Serum LC",30986334,CDM,309,RC,86334,CPT,,,Inpatient,,,140,,,,80,,112,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,133,
"Immunofixation, Serum LC",30986334,CDM,309,RC,86334,CPT,,,Inpatient,,,200,,,,80,,160,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,155.4,percent of total billed charges,,,95,,190,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,190,
AFP Tetra - LC,30986336,CDM,309,RC,86336,CPT,,,Outpatient,,,213,,,,80,,170.4,percent of total billed charges,,,,50,50.25,fee schedule,,,77.7,,165.5,percent of total billed charges,,,95,,202.35,percent of total billed charges,,,60,,127.8,percent of total billed charges,,127.8,202.35,
AFP Tetra - LC,30986336,CDM,309,RC,86336,CPT,,,Inpatient,,,213,,,,80,,170.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,165.5,percent of total billed charges,,,95,,202.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,202.35,
Glutamic Acid Decarboxylase (GAD) Autoantibody - LC,30986341,CDM,309,RC,86341,CPT,,,Outpatient,,,134,,,,80,,107.2,percent of total billed charges,,,,50,39.94,fee schedule,,,77.7,,104.12,percent of total billed charges,,,95,,127.3,percent of total billed charges,,,60,,80.4,percent of total billed charges,,80.4,127.3,
Glutamic Acid Decarboxylase (GAD) Autoantibody - LC,30986341,CDM,309,RC,86341,CPT,,,Inpatient,,,134,,,,80,,107.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,104.12,percent of total billed charges,,,95,,127.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,127.3,
CD4/CD8 Ratio Profile LC,30986360,CDM,309,RC,86360,CPT,,,Outpatient,,,328,,,,80,,262.4,percent of total billed charges,,,,50,68.06,fee schedule,,,77.7,,254.86,percent of total billed charges,,,95,,311.6,percent of total billed charges,,,60,,196.8,percent of total billed charges,,196.8,311.6,
CD4/CD8 Ratio Profile LC,30986360,CDM,309,RC,86360,CPT,,,Inpatient,,,328,,,,80,,262.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,254.86,percent of total billed charges,,,95,,311.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,311.6,
86364 TISS TRNSGLTMNASE EA IG CLAS LC,30986364,CDM,309,RC,86364,CPT,,,Outpatient,,,30,,,,80,,24,percent of total billed charges,,,,85,25.5,percent of total billed charges,,,77.7,,23.31,percent of total billed charges,,,95,,28.5,percent of total billed charges,,,60,,18,percent of total billed charges,,18,28.5,
86364 TISSUE TRANSGLUTAMINASE EA IMMUNOGLOBULIN CLASS LC,30986364,CDM,309,RC,86364,CPT,,,Outpatient,,,45,,,,80,,36,percent of total billed charges,,,,85,38.25,percent of total billed charges,,,77.7,,34.97,percent of total billed charges,,,95,,42.75,percent of total billed charges,,,60,,27,percent of total billed charges,,27,42.75,
86364 Tissue transglutaminase ea IG class LC,30986364,CDM,309,RC,86364,CPT,,,Outpatient,,,75,,,,80,,60,percent of total billed charges,,,,85,63.75,percent of total billed charges,,,77.7,,58.28,percent of total billed charges,,,95,,71.25,percent of total billed charges,,,60,,45,percent of total billed charges,,45,71.25,
86364 TISS TRNSGLTMNASE EA IG CLAS LC,30986364,CDM,309,RC,86364,CPT,,,Inpatient,,,30,,,,80,,24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,23.31,percent of total billed charges,,,95,,28.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,28.5,
86364 TISSUE TRANSGLUTAMINASE EA IMMUNOGLOBULIN CLASS LC,30986364,CDM,309,RC,86364,CPT,,,Inpatient,,,45,,,,80,,36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,34.97,percent of total billed charges,,,95,,42.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,42.75,
86364 Tissue transglutaminase ea IG class LC,30986364,CDM,309,RC,86364,CPT,,,Inpatient,,,75,,,,80,,60,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,58.28,percent of total billed charges,,,95,,71.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,71.25,
86376 Microsomal Antibodies each,30986376,CDM,309,RC,86376,CPT,,,Outpatient,,,129,,,,80,,103.2,percent of total billed charges,,,,50,25.48,fee schedule,,,77.7,,100.23,percent of total billed charges,,,95,,122.55,percent of total billed charges,,,60,,77.4,percent of total billed charges,,77.4,122.55,
Anti-Smooth Muscle/Mitochond. - LC,30986376,CDM,309,RC,86376,CPT,,,Outpatient,,,95,,,,80,,76,percent of total billed charges,,,,50,25.48,fee schedule,,,77.7,,73.82,percent of total billed charges,,,95,,90.25,percent of total billed charges,,,60,,57,percent of total billed charges,,57,90.25,
86376 Microsomal Antibodies each,30986376,CDM,309,RC,86376,CPT,,,Inpatient,,,129,,,,80,,103.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,100.23,percent of total billed charges,,,95,,122.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,122.55,
Anti-Smooth Muscle/Mitochond. - LC,30986376,CDM,309,RC,86376,CPT,,,Inpatient,,,95,,,,80,,76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,73.82,percent of total billed charges,,,95,,90.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,90.25,
86381 Mitochondrial antibody ea LC,30986381,CDM,309,RC,86381,CPT,,,Outpatient,,,160,,,,80,,128,percent of total billed charges,,,,50,23.86,fee schedule,,,77.7,,124.32,percent of total billed charges,,,95,,152,percent of total billed charges,,,60,,96,percent of total billed charges,,96,152,
Anti-Mitochondrial Ab by IFA - LC,30986381,CDM,309,RC,86381,CPT,,,Outpatient,,,73,,,,80,,58.4,percent of total billed charges,,,,50,23.86,fee schedule,,,77.7,,56.72,percent of total billed charges,,,95,,69.35,percent of total billed charges,,,60,,43.8,percent of total billed charges,,43.8,69.35,
86381 Mitochondrial antibody ea LC,30986381,CDM,309,RC,86381,CPT,,,Inpatient,,,160,,,,80,,128,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,124.32,percent of total billed charges,,,95,,152,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,152,
Anti-Mitochondrial Ab by IFA - LC,30986381,CDM,309,RC,86381,CPT,,,Inpatient,,,73,,,,80,,58.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,56.72,percent of total billed charges,,,95,,69.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,69.35,
86431 RHEUMATOID FACTOR QUANTITATIVE LC,30986431,CDM,309,RC,86431,CPT,,,Outpatient,,,70,,,,80,,56,percent of total billed charges,,,,50,12.87,fee schedule,,,77.7,,54.39,percent of total billed charges,,,95,,66.5,percent of total billed charges,,,60,,42,percent of total billed charges,,42,66.5,
Systemic Lupus Profile A - LC,30986431,CDM,309,RC,86431,CPT,,,Outpatient,,,70,,,,80,,56,percent of total billed charges,,,,50,12.87,fee schedule,,,77.7,,54.39,percent of total billed charges,,,95,,66.5,percent of total billed charges,,,60,,42,percent of total billed charges,,42,66.5,
86431 RHEUMATOID FACTOR QUANTITATIVE LC,30986431,CDM,309,RC,86431,CPT,,,Inpatient,,,70,,,,80,,56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,54.39,percent of total billed charges,,,95,,66.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,66.5,
Systemic Lupus Profile A - LC,30986431,CDM,309,RC,86431,CPT,,,Inpatient,,,70,,,,80,,56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,54.39,percent of total billed charges,,,95,,66.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,66.5,
QFT-TB Plus(Client Incubated) - LC,30986480,CDM,309,RC,86480,CPT,,,Outpatient,,,166,,,,80,,132.8,percent of total billed charges,,,,50,66.5,fee schedule,,,77.7,,128.98,percent of total billed charges,,,95,,157.7,percent of total billed charges,,,60,,99.6,percent of total billed charges,,99.6,157.7,
QuantiFERON Client Incubated LC,30986480,CDM,309,RC,86480,CPT,,,Outpatient,,,200,,,,80,,160,percent of total billed charges,,,,50,66.5,fee schedule,,,77.7,,155.4,percent of total billed charges,,,95,,190,percent of total billed charges,,,60,,120,percent of total billed charges,,120,190,
QuantiFERON TB Gold (In Tube) LC,30986480,CDM,309,RC,86480,CPT,,,Outpatient,,,166,,,,80,,132.8,percent of total billed charges,,,,50,66.5,fee schedule,,,77.7,,128.98,percent of total billed charges,,,95,,157.7,percent of total billed charges,,,60,,99.6,percent of total billed charges,,99.6,157.7,
QuantiFERON-TB Gold Plus (1 tube) - LC,30986480,CDM,309,RC,86480,CPT,,,Outpatient,,,200,,,,80,,160,percent of total billed charges,,,,50,66.5,fee schedule,,,77.7,,155.4,percent of total billed charges,,,95,,190,percent of total billed charges,,,60,,120,percent of total billed charges,,120,190,
QFT-TB Plus(Client Incubated) - LC,30986480,CDM,309,RC,86480,CPT,,,Inpatient,,,166,,,,80,,132.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,128.98,percent of total billed charges,,,95,,157.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,157.7,
QuantiFERON Client Incubated LC,30986480,CDM,309,RC,86480,CPT,,,Inpatient,,,200,,,,80,,160,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,155.4,percent of total billed charges,,,95,,190,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,190,
QuantiFERON TB Gold (In Tube) LC,30986480,CDM,309,RC,86480,CPT,,,Inpatient,,,166,,,,80,,132.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,128.98,percent of total billed charges,,,95,,157.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,157.7,
QuantiFERON-TB Gold Plus (1 tube) - LC,30986480,CDM,309,RC,86480,CPT,,,Inpatient,,,200,,,,80,,160,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,155.4,percent of total billed charges,,,95,,190,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,190,
RPR - LC,30986592,CDM,309,RC,86592,CPT,,,Outpatient,,,46,,,,80,,36.8,percent of total billed charges,,,,50,8.13,fee schedule,,,77.7,,35.74,percent of total billed charges,,,95,,43.7,percent of total billed charges,,,60,,27.6,percent of total billed charges,,27.6,43.7,
RPR - LC,30986592,CDM,309,RC,86592,CPT,,,Inpatient,,,46,,,,80,,36.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,35.74,percent of total billed charges,,,95,,43.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,43.7,
86593 Syphilis test non-trep quant LC,30986593,CDM,309,RC,86593,CPT,,,Outpatient,,,63,,,,80,,50.4,percent of total billed charges,,,,50,11.28,fee schedule,,,77.7,,48.95,percent of total billed charges,,,95,,59.85,percent of total billed charges,,,60,,37.8,percent of total billed charges,,37.8,59.85,
86593 Syphilis test non-trep quant LC,30986593,CDM,309,RC,86593,CPT,,,Inpatient,,,63,,,,80,,50.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,48.95,percent of total billed charges,,,95,,59.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,59.85,
86611 Bartonella Antibody,30986611,CDM,309,RC,86611,CPT,,,Outpatient,,,28,,,,80,,22.4,percent of total billed charges,,,,50,9.62,fee schedule,,,77.7,,21.76,percent of total billed charges,,,95,,26.6,percent of total billed charges,,,60,,16.8,percent of total billed charges,,16.8,26.6,
Bartonella Antibody Panel - LC,30986611,CDM,309,RC,86611,CPT,,,Outpatient,,,28,,,,80,,22.4,percent of total billed charges,,,,50,9.62,fee schedule,,,77.7,,21.76,percent of total billed charges,,,95,,26.6,percent of total billed charges,,,60,,16.8,percent of total billed charges,,16.8,26.6,
86611 Bartonella Antibody,30986611,CDM,309,RC,86611,CPT,,,Inpatient,,,28,,,,80,,22.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,21.76,percent of total billed charges,,,95,,26.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,26.6,
Bartonella Antibody Panel - LC,30986611,CDM,309,RC,86611,CPT,,,Inpatient,,,28,,,,80,,22.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,21.76,percent of total billed charges,,,95,,26.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,26.6,
"Blastomyces Abs, Qn, DID LC",30986612,CDM,309,RC,86612,CPT,,,Outpatient,,,51,,,,80,,40.8,percent of total billed charges,,,,50,6.74,fee schedule,,,77.7,,39.63,percent of total billed charges,,,95,,48.45,percent of total billed charges,,,60,,30.6,percent of total billed charges,,30.6,48.45,
"Blastomyces Abs, Qn, DID LC",30986612,CDM,309,RC,86612,CPT,,,Inpatient,,,51,,,,80,,40.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,39.63,percent of total billed charges,,,95,,48.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,48.45,
86615 BORDETELLA ANTIBODY,30986615,CDM,309,RC,86615,CPT,,,Outpatient,,,72,,,,80,,57.6,percent of total billed charges,,,,50,9.68,fee schedule,,,77.7,,55.94,percent of total billed charges,,,95,,68.4,percent of total billed charges,,,60,,43.2,percent of total billed charges,,43.2,68.4,
B pertussis IgG/M/A Ab LC,30986615,CDM,309,RC,86615,CPT,,,Outpatient,,,72,,,,80,,57.6,percent of total billed charges,,,,50,9.68,fee schedule,,,77.7,,55.94,percent of total billed charges,,,95,,68.4,percent of total billed charges,,,60,,43.2,percent of total billed charges,,43.2,68.4,
B pertussis IgM Ab LC,30986615,CDM,309,RC,86615,CPT,,,Outpatient,,,72,,,,80,,57.6,percent of total billed charges,,,,50,9.68,fee schedule,,,77.7,,55.94,percent of total billed charges,,,95,,68.4,percent of total billed charges,,,60,,43.2,percent of total billed charges,,43.2,68.4,
"Respiratory Pathogen Profile, PCR - LC",30986615,CDM,309,RC,86615,CPT,,,Outpatient,,,30,,,,80,,24,percent of total billed charges,,,,50,9.68,fee schedule,,,77.7,,23.31,percent of total billed charges,,,95,,28.5,percent of total billed charges,,,60,,18,percent of total billed charges,,18,28.5,
86615 BORDETELLA ANTIBODY,30986615,CDM,309,RC,86615,CPT,,,Inpatient,,,72,,,,80,,57.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,55.94,percent of total billed charges,,,95,,68.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,68.4,
B pertussis IgG/M/A Ab LC,30986615,CDM,309,RC,86615,CPT,,,Inpatient,,,72,,,,80,,57.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,55.94,percent of total billed charges,,,95,,68.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,68.4,
B pertussis IgM Ab LC,30986615,CDM,309,RC,86615,CPT,,,Inpatient,,,72,,,,80,,57.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,55.94,percent of total billed charges,,,95,,68.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,68.4,
"Respiratory Pathogen Profile, PCR - LC",30986615,CDM,309,RC,86615,CPT,,,Inpatient,,,30,,,,80,,24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,23.31,percent of total billed charges,,,95,,28.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,28.5,
86617 ANTIBODY BORRELIA BURGDORFERI CONFIRMATORY TST LC,30986617,CDM,309,RC,86617,CPT,,,Outpatient,,,132.5,,,,80,,106,percent of total billed charges,,,,50,50.86,fee schedule,,,77.7,,102.95,percent of total billed charges,,,95,,125.88,percent of total billed charges,,,60,,79.5,percent of total billed charges,,79.5,125.88,
"Lyme, Western Blot Serum - LC",30986617,CDM,309,RC,86617,CPT,,,Outpatient,,,132.5,,,,80,,106,percent of total billed charges,,,,50,50.86,fee schedule,,,77.7,,102.95,percent of total billed charges,,,95,,125.88,percent of total billed charges,,,60,,79.5,percent of total billed charges,,79.5,125.88,
86617 ANTIBODY BORRELIA BURGDORFERI CONFIRMATORY TST LC,30986617,CDM,309,RC,86617,CPT,,,Inpatient,,,132.5,,,,80,,106,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,102.95,percent of total billed charges,,,95,,125.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,125.88,
"Lyme, Western Blot Serum - LC",30986617,CDM,309,RC,86617,CPT,,,Inpatient,,,132.5,,,,80,,106,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,102.95,percent of total billed charges,,,95,,125.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,125.88,
Lyme Disease Serology w/ Reflex - LC,30986618,CDM,309,RC,86618,CPT,,,Outpatient,,,219,,,,80,,175.2,percent of total billed charges,,,,50,38.34,fee schedule,,,77.7,,170.16,percent of total billed charges,,,95,,208.05,percent of total billed charges,,,60,,131.4,percent of total billed charges,,131.4,208.05,
Lyme Disease Serology w/ Reflex - LC,30986618,CDM,309,RC,86618,CPT,,,Inpatient,,,219,,,,80,,175.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,170.16,percent of total billed charges,,,95,,208.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,208.05,
"Coccidioides Abs, Qn, DID LC",30986635,CDM,309,RC,86635,CPT,,,Outpatient,,,110,,,,80,,88,percent of total billed charges,,,,50,25.91,fee schedule,,,77.7,,85.47,percent of total billed charges,,,95,,104.5,percent of total billed charges,,,60,,66,percent of total billed charges,,66,104.5,
"Coccidioides Abs, Qn, DID LC",30986635,CDM,309,RC,86635,CPT,,,Inpatient,,,110,,,,80,,88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,85.47,percent of total billed charges,,,95,,104.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,104.5,
"Cryptococcus Antibodies, Quantitative - LC",30986641,CDM,309,RC,86641,CPT,,,Outpatient,,,95,,,,80,,76,percent of total billed charges,,,,50,23.33,fee schedule,,,77.7,,73.82,percent of total billed charges,,,95,,90.25,percent of total billed charges,,,60,,57,percent of total billed charges,,57,90.25,
"Cryptococcus Antibodies, Quantitative - LC",30986641,CDM,309,RC,86641,CPT,,,Inpatient,,,95,,,,80,,76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,73.82,percent of total billed charges,,,95,,90.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,90.25,
"EBV Early Antigen Ab, IgG - LC",30986663,CDM,309,RC,86663,CPT,,,Outpatient,,,167,,,,80,,133.6,percent of total billed charges,,,,50,29.95,fee schedule,,,77.7,,129.76,percent of total billed charges,,,95,,158.65,percent of total billed charges,,,60,,100.2,percent of total billed charges,,100.2,158.65,
"EBV Early Antigen Ab, IgG - LC",30986663,CDM,309,RC,86663,CPT,,,Inpatient,,,167,,,,80,,133.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,129.76,percent of total billed charges,,,95,,158.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,158.65,
86664 Epstein-barr nuclear antigen LC,30986664,CDM,309,RC,86664,CPT,,,Outpatient,,,231,,,,80,,184.8,percent of total billed charges,,,,50,31.3,fee schedule,,,77.7,,179.49,percent of total billed charges,,,95,,219.45,percent of total billed charges,,,60,,138.6,percent of total billed charges,,138.6,219.45,
EBV Antibody Profile - LC,30986664,CDM,309,RC,86664,CPT,,,Outpatient,,,222,,,,80,,177.6,percent of total billed charges,,,,50,31.3,fee schedule,,,77.7,,172.49,percent of total billed charges,,,95,,210.9,percent of total billed charges,,,60,,133.2,percent of total billed charges,,133.2,210.9,
86664 Epstein-barr nuclear antigen LC,30986664,CDM,309,RC,86664,CPT,,,Inpatient,,,231,,,,80,,184.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,179.49,percent of total billed charges,,,95,,219.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,219.45,
EBV Antibody Profile - LC,30986664,CDM,309,RC,86664,CPT,,,Inpatient,,,222,,,,80,,177.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,172.49,percent of total billed charges,,,95,,210.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,210.9,
86665 Epstein-barr antibody profile,30986665,CDM,309,RC,86665,CPT,,,Outpatient,,,227,,,,80,,181.6,percent of total billed charges,,,,50,32.44,fee schedule,,,77.7,,176.38,percent of total billed charges,,,95,,215.65,percent of total billed charges,,,60,,136.2,percent of total billed charges,,136.2,215.65,
"EBV Ab VCA, IgM - LC",30986665,CDM,309,RC,86665,CPT,,,Outpatient,,,227,,,,80,,181.6,percent of total billed charges,,,,50,32.44,fee schedule,,,77.7,,176.38,percent of total billed charges,,,95,,215.65,percent of total billed charges,,,60,,136.2,percent of total billed charges,,136.2,215.65,
86665 Epstein-barr antibody profile,30986665,CDM,309,RC,86665,CPT,,,Inpatient,,,227,,,,80,,181.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,176.38,percent of total billed charges,,,95,,215.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,215.65,
"EBV Ab VCA, IgM - LC",30986665,CDM,309,RC,86665,CPT,,,Inpatient,,,227,,,,80,,181.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,176.38,percent of total billed charges,,,95,,215.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,215.65,
86671 ANTIBODY FUNGUS NOT ELSEWHERE SPECIFIED LC,30986671,CDM,309,RC,86671,CPT,,,Outpatient,,,51,,,,80,,40.8,percent of total billed charges,,,,50,15.14,fee schedule,,,77.7,,39.63,percent of total billed charges,,,95,,48.45,percent of total billed charges,,,60,,30.6,percent of total billed charges,,30.6,48.45,
86671 ANTIBODY FUNGUS NOT ELSEWHERE SPECIFIED LC,30986671,CDM,309,RC,86671,CPT,,,Inpatient,,,51,,,,80,,40.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,39.63,percent of total billed charges,,,95,,48.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,48.45,
"H pylori, IgM, IgG, IgA Abs - LC",30986677,CDM,309,RC,86677,CPT,,,Outpatient,,,75,,,,80,,60,percent of total billed charges,,,,50,19.88,fee schedule,,,77.7,,58.28,percent of total billed charges,,,95,,71.25,percent of total billed charges,,,60,,45,percent of total billed charges,,45,71.25,
"H pylori, IgM, IgG, IgA Abs - LC",30986677,CDM,309,RC,86677,CPT,,,Inpatient,,,75,,,,80,,60,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,58.28,percent of total billed charges,,,95,,71.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,71.25,
86695 Herpes simplex type 1 test LC,30986695,CDM,309,RC,86695,CPT,,,Outpatient,,,125,,,,80,,100,percent of total billed charges,,,,50,31.77,fee schedule,,,77.7,,97.13,percent of total billed charges,,,95,,118.75,percent of total billed charges,,,60,,75,percent of total billed charges,,75,118.75,
86695 Herpes simplex type 1 test LC,30986695,CDM,309,RC,86695,CPT,,,Inpatient,,,125,,,,80,,100,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,97.13,percent of total billed charges,,,95,,118.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,118.75,
"HSV 1 and 2-Specific Ab, IgG LC",30986696,CDM,309,RC,86696,CPT,,,Outpatient,,,135,,,,80,,108,percent of total billed charges,,,,50,33.53,fee schedule,,,77.7,,104.9,percent of total billed charges,,,95,,128.25,percent of total billed charges,,,60,,81,percent of total billed charges,,81,128.25,
"HSV 1 and 2-Specific Ab, IgG LC",30986696,CDM,309,RC,86696,CPT,,,Inpatient,,,135,,,,80,,108,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,104.9,percent of total billed charges,,,95,,128.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,128.25,
86704 Hep B core antibody total LC,30986704,CDM,309,RC,86704,CPT,,,Outpatient,,,116,,,,80,,92.8,percent of total billed charges,,,,50,22.12,fee schedule,,,77.7,,90.13,percent of total billed charges,,,95,,110.2,percent of total billed charges,,,60,,69.6,percent of total billed charges,,69.6,110.2,
86704 Hep B core antibody total LC,30986704,CDM,309,RC,86704,CPT,,,Inpatient,,,116,,,,80,,92.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,90.13,percent of total billed charges,,,95,,110.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,110.2,
86705 Hep B core antibody IGM LC,30986705,CDM,309,RC,86705,CPT,,,Outpatient,,,141,,,,80,,112.8,percent of total billed charges,,,,50,17.05,fee schedule,,,77.7,,109.56,percent of total billed charges,,,95,,133.95,percent of total billed charges,,,60,,84.6,percent of total billed charges,,84.6,133.95,
"Hep B Core Ab, IgM - LC",30986705,CDM,309,RC,86705,CPT,,,Outpatient,,,141,,,,80,,112.8,percent of total billed charges,,,,50,17.05,fee schedule,,,77.7,,109.56,percent of total billed charges,,,95,,133.95,percent of total billed charges,,,60,,84.6,percent of total billed charges,,84.6,133.95,
86705 Hep B core antibody IGM LC,30986705,CDM,309,RC,86705,CPT,,,Inpatient,,,141,,,,80,,112.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,109.56,percent of total billed charges,,,95,,133.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,133.95,
"Hep B Core Ab, IgM - LC",30986705,CDM,309,RC,86705,CPT,,,Inpatient,,,141,,,,80,,112.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,109.56,percent of total billed charges,,,95,,133.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,133.95,
86706 Hep b surface antibody LC,30986706,CDM,309,RC,86706,CPT,,,Outpatient,,,135,,,,80,,108,percent of total billed charges,,,,50,23.18,fee schedule,,,77.7,,104.9,percent of total billed charges,,,95,,128.25,percent of total billed charges,,,60,,81,percent of total billed charges,,81,128.25,
86706 Hep b surface antibody LC,30986706,CDM,309,RC,86706,CPT,,,Inpatient,,,135,,,,80,,108,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,104.9,percent of total billed charges,,,95,,128.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,128.25,
86707 Hepatitis BE antibody LC,30986707,CDM,309,RC,86707,CPT,,,Outpatient,,,115,,,,80,,92,percent of total billed charges,,,,50,21.69,fee schedule,,,77.7,,89.36,percent of total billed charges,,,95,,109.25,percent of total billed charges,,,60,,69,percent of total billed charges,,69,109.25,
Hep Be Ab LC,30986707,CDM,309,RC,86707,CPT,,,Outpatient,,,115,,,,80,,92,percent of total billed charges,,,,50,21.69,fee schedule,,,77.7,,89.36,percent of total billed charges,,,95,,109.25,percent of total billed charges,,,60,,69,percent of total billed charges,,69,109.25,
86707 Hepatitis BE antibody LC,30986707,CDM,309,RC,86707,CPT,,,Inpatient,,,115,,,,80,,92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,89.36,percent of total billed charges,,,95,,109.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,109.25,
Hep Be Ab LC,30986707,CDM,309,RC,86707,CPT,,,Inpatient,,,115,,,,80,,92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,89.36,percent of total billed charges,,,95,,109.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,109.25,
"Hep A Antibody, IgM - LC",30986709,CDM,309,RC,86709,CPT,,,Outpatient,,,139,,,,80,,111.2,percent of total billed charges,,,,50,24.98,fee schedule,,,77.7,,108,percent of total billed charges,,,95,,132.05,percent of total billed charges,,,60,,83.4,percent of total billed charges,,83.4,132.05,
"Hep A Antibody, IgM - LC",30986709,CDM,309,RC,86709,CPT,,,Inpatient,,,139,,,,80,,111.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,108,percent of total billed charges,,,95,,132.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,132.05,
Measles/Mumps/Rubella Immunity LC,30986735,CDM,309,RC,86735,CPT,,,Outpatient,,,169,,,,80,,135.2,percent of total billed charges,,,,50,32.48,fee schedule,,,77.7,,131.31,percent of total billed charges,,,95,,160.55,percent of total billed charges,,,60,,101.4,percent of total billed charges,,101.4,160.55,
Measles/Mumps/Rubella Immunity LC,30986735,CDM,309,RC,86735,CPT,,,Inpatient,,,169,,,,80,,135.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,131.31,percent of total billed charges,,,95,,160.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,160.55,
86747 PARVOVIRUS ANTIBODY LC,30986747,CDM,309,RC,86747,CPT,,,Outpatient,,,107.5,,,,80,,86,percent of total billed charges,,,,50,39.63,fee schedule,,,77.7,,83.53,percent of total billed charges,,,95,,102.13,percent of total billed charges,,,60,,64.5,percent of total billed charges,,64.5,102.13,
"Parvovirus B19 (Human), IgG, IgM - LC",30986747,CDM,309,RC,86747,CPT,,,Outpatient,,,107.5,,,,80,,86,percent of total billed charges,,,,50,39.63,fee schedule,,,77.7,,83.53,percent of total billed charges,,,95,,102.13,percent of total billed charges,,,60,,64.5,percent of total billed charges,,64.5,102.13,
86747 PARVOVIRUS ANTIBODY LC,30986747,CDM,309,RC,86747,CPT,,,Inpatient,,,107.5,,,,80,,86,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,83.53,percent of total billed charges,,,95,,102.13,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,102.13,
"Parvovirus B19 (Human), IgG, IgM - LC",30986747,CDM,309,RC,86747,CPT,,,Inpatient,,,107.5,,,,80,,86,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,83.53,percent of total billed charges,,,95,,102.13,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,102.13,
86757 ANTIBODY RICKETTSIA LC,30986757,CDM,309,RC,86757,CPT,,,Outpatient,,,82.5,,,,80,,66,percent of total billed charges,,,,50,63.27,fee schedule,,,77.7,,64.1,percent of total billed charges,,,95,,78.38,percent of total billed charges,,,60,,49.5,percent of total billed charges,,49.5,78.38,
"Rocky Mtn Spotted Fev, IgG, Qn - LC",30986757,CDM,309,RC,86757,CPT,,,Outpatient,,,328,,,,80,,262.4,percent of total billed charges,,,,50,63.27,fee schedule,,,77.7,,254.86,percent of total billed charges,,,95,,311.6,percent of total billed charges,,,60,,196.8,percent of total billed charges,,196.8,311.6,
"Spotted Fever Group Antibodies, IgG and IgM - LC",30986757,CDM,309,RC,86757,CPT,,,Outpatient,,,82.5,,,,80,,66,percent of total billed charges,,,,50,63.27,fee schedule,,,77.7,,64.1,percent of total billed charges,,,95,,78.38,percent of total billed charges,,,60,,49.5,percent of total billed charges,,49.5,78.38,
86757 ANTIBODY RICKETTSIA LC,30986757,CDM,309,RC,86757,CPT,,,Inpatient,,,82.5,,,,80,,66,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,64.1,percent of total billed charges,,,95,,78.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,78.38,
"Rocky Mtn Spotted Fev, IgG, Qn - LC",30986757,CDM,309,RC,86757,CPT,,,Inpatient,,,328,,,,80,,262.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,254.86,percent of total billed charges,,,95,,311.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,311.6,
"Spotted Fever Group Antibodies, IgG and IgM - LC",30986757,CDM,309,RC,86757,CPT,,,Inpatient,,,82.5,,,,80,,66,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,64.1,percent of total billed charges,,,95,,78.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,78.38,
86762 Rubella Antibodies IgG,30986762,CDM,309,RC,86762,CPT,,,Outpatient,,,45,,,,80,,36,percent of total billed charges,,,,50,15.45,fee schedule,,,77.7,,34.97,percent of total billed charges,,,95,,42.75,percent of total billed charges,,,60,,27,percent of total billed charges,,27,42.75,
86762 Rubella Antibodies IgG,30986762,CDM,309,RC,86762,CPT,,,Inpatient,,,45,,,,80,,36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,34.97,percent of total billed charges,,,95,,42.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,42.75,
86765 Rubeola Antibodies IgG,30986765,CDM,309,RC,86765,CPT,,,Outpatient,,,145,,,,80,,116,percent of total billed charges,,,,50,34.14,fee schedule,,,77.7,,112.67,percent of total billed charges,,,95,,137.75,percent of total billed charges,,,60,,87,percent of total billed charges,,87,137.75,
86765 Rubeola Antibodies IgG,30986765,CDM,309,RC,86765,CPT,,,Inpatient,,,145,,,,80,,116,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,112.67,percent of total billed charges,,,95,,137.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,137.75,
Treponema pallidum Antibodies - LC,30986780,CDM,309,RC,86780,CPT,,,Outpatient,,,141,,,,80,,112.8,percent of total billed charges,,,,50,26.56,fee schedule,,,77.7,,109.56,percent of total billed charges,,,95,,133.95,percent of total billed charges,,,60,,84.6,percent of total billed charges,,84.6,133.95,
Treponema pallidum Antibodies - LC,30986780,CDM,309,RC,86780,CPT,,,Inpatient,,,141,,,,80,,112.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,109.56,percent of total billed charges,,,95,,133.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,133.95,
"West Nile Virus Antibody,Serum LC",30986788,CDM,309,RC,86788,CPT,,,Outpatient,,,157,,,,80,,125.6,percent of total billed charges,,,,50,18.08,fee schedule,,,77.7,,121.99,percent of total billed charges,,,95,,149.15,percent of total billed charges,,,60,,94.2,percent of total billed charges,,94.2,149.15,
"West Nile Virus Antibody,Serum LC",30986788,CDM,309,RC,86788,CPT,,,Inpatient,,,157,,,,80,,125.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,121.99,percent of total billed charges,,,95,,149.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,149.15,
86789 WEST NILE VIRUS ANTIBODY LC,30986789,CDM,309,RC,86789,CPT,,,Outpatient,,,157,,,,80,,125.6,percent of total billed charges,,,,50,15.45,fee schedule,,,77.7,,121.99,percent of total billed charges,,,95,,149.15,percent of total billed charges,,,60,,94.2,percent of total billed charges,,94.2,149.15,
86789 WEST NILE VIRUS ANTIBODY LC,30986789,CDM,309,RC,86789,CPT,,,Inpatient,,,157,,,,80,,125.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,121.99,percent of total billed charges,,,95,,149.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,149.15,
86800 Thyroglobulin antibody LC,30986800,CDM,309,RC,86800,CPT,,,Outpatient,,,190,,,,80,,152,percent of total billed charges,,,,50,34.54,fee schedule,,,77.7,,147.63,percent of total billed charges,,,95,,180.5,percent of total billed charges,,,60,,114,percent of total billed charges,,114,180.5,
"TgAb+Thyroglobulin,IMA or RIA LC",30986800,CDM,309,RC,86800,CPT,,,Outpatient,,,95,,,,80,,76,percent of total billed charges,,,,50,34.54,fee schedule,,,77.7,,73.82,percent of total billed charges,,,95,,90.25,percent of total billed charges,,,60,,57,percent of total billed charges,,57,90.25,
86800 Thyroglobulin antibody LC,30986800,CDM,309,RC,86800,CPT,,,Inpatient,,,190,,,,80,,152,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,147.63,percent of total billed charges,,,95,,180.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,180.5,
"TgAb+Thyroglobulin,IMA or RIA LC",30986800,CDM,309,RC,86800,CPT,,,Inpatient,,,95,,,,80,,76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,73.82,percent of total billed charges,,,95,,90.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,90.25,
HCV Ab w/ Reflex to Quant RT PCR - LC,30986803,CDM,309,RC,86803,CPT,,,Outpatient,,,152,,,,80,,121.6,percent of total billed charges,,,,50,22.55,fee schedule,,,77.7,,118.1,percent of total billed charges,,,95,,144.4,percent of total billed charges,,,60,,91.2,percent of total billed charges,,91.2,144.4,
HCV Antibody LC,30986803,CDM,309,RC,86803,CPT,,,Outpatient,,,152,,,,80,,121.6,percent of total billed charges,,,,50,22.55,fee schedule,,,77.7,,118.1,percent of total billed charges,,,95,,144.4,percent of total billed charges,,,60,,91.2,percent of total billed charges,,91.2,144.4,
HCV Ab w/ Reflex to Quant RT PCR - LC,30986803,CDM,309,RC,86803,CPT,,,Inpatient,,,152,,,,80,,121.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,118.1,percent of total billed charges,,,95,,144.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,144.4,
HCV Antibody LC,30986803,CDM,309,RC,86803,CPT,,,Inpatient,,,152,,,,80,,121.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,118.1,percent of total billed charges,,,95,,144.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,144.4,
Antibody Screen - LC,30986850,CDM,309,RC,86850,CPT,,,Outpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,50,45.64,fee schedule,,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,60,,157.06,percent of total billed charges,,157.06,248.68,
Antibody Screen - LC,30986850,CDM,309,RC,86850,CPT,,,Inpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,248.68,
Salmonella/Shigella Screen LC,30987045,CDM,309,RC,87045,CPT,,,Outpatient,,,65,,,,80,,52,percent of total billed charges,,,,50,14.81,fee schedule,,,77.7,,50.51,percent of total billed charges,,,95,,61.75,percent of total billed charges,,,60,,39,percent of total billed charges,,39,61.75,
Salmonella/Shigella Screen LC,30987045,CDM,309,RC,87045,CPT,,,Inpatient,,,65,,,,80,,52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,50.51,percent of total billed charges,,,95,,61.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,61.75,
87046 Stool cultr aerobic bact ea LC,30987046,CDM,309,RC,87046,CPT,,,Outpatient,,,65,,,,80,,52,percent of total billed charges,,,,50,14.81,fee schedule,,,77.7,,50.51,percent of total billed charges,,,95,,61.75,percent of total billed charges,,,60,,39,percent of total billed charges,,39,61.75,
87046 Stool cultr aerobic bact ea LC,30987046,CDM,309,RC,87046,CPT,,,Inpatient,,,65,,,,80,,52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,50.51,percent of total billed charges,,,95,,61.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,61.75,
"87070 Culture, bacterial; any other source except urine, blood or stool",30987070,CDM,309,RC,87070,CPT,,,Outpatient,,,85,,,,80,,68,percent of total billed charges,,,,50,15.94,fee schedule,,,77.7,,66.05,percent of total billed charges,,,95,,80.75,percent of total billed charges,,,60,,51,percent of total billed charges,,51,80.75,
Anaerobic/Aerobic/Gram Stain LC,30987070,CDM,309,RC,87070,CPT,,,Outpatient,,,85,,,,80,,68,percent of total billed charges,,,,50,15.94,fee schedule,,,77.7,,66.05,percent of total billed charges,,,95,,80.75,percent of total billed charges,,,60,,51,percent of total billed charges,,51,80.75,
"87070 Culture, bacterial; any other source except urine, blood or stool",30987070,CDM,309,RC,87070,CPT,,,Inpatient,,,85,,,,80,,68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,66.05,percent of total billed charges,,,95,,80.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,80.75,
Anaerobic/Aerobic/Gram Stain LC,30987070,CDM,309,RC,87070,CPT,,,Inpatient,,,85,,,,80,,68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,66.05,percent of total billed charges,,,95,,80.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,80.75,
"87075 Culture, bacterial: any source except blood, anaerobic with isolation",30987075,CDM,309,RC,87075,CPT,,,Outpatient,,,85,,,,80,,68,percent of total billed charges,,,,50,15.61,fee schedule,,,77.7,,66.05,percent of total billed charges,,,95,,80.75,percent of total billed charges,,,60,,51,percent of total billed charges,,51,80.75,
"87075 Culture, bacterial: any source except blood, anaerobic with isolation",30987075,CDM,309,RC,87075,CPT,,,Outpatient,,,85,,,,80,,68,percent of total billed charges,,,,50,15.61,fee schedule,,,77.7,,66.05,percent of total billed charges,,,95,,80.75,percent of total billed charges,,,60,,51,percent of total billed charges,,51,80.75,
"87075 Culture, bacterial: any source except blood, anaerobic with isolation",30987075,CDM,309,RC,87075,CPT,,,Inpatient,,,85,,,,80,,68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,66.05,percent of total billed charges,,,95,,80.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,80.75,
"87075 Culture, bacterial: any source except blood, anaerobic with isolation",30987075,CDM,309,RC,87075,CPT,,,Inpatient,,,85,,,,80,,68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,66.05,percent of total billed charges,,,95,,80.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,80.75,
87081 Culture screen only LC,30987081,CDM,309,RC,87081,CPT,,,Outpatient,,,63,,,,80,,50.4,percent of total billed charges,,,,50,11.98,fee schedule,,,77.7,,48.95,percent of total billed charges,,,95,,59.85,percent of total billed charges,,,60,,37.8,percent of total billed charges,,37.8,59.85,
Beta Strep Gp A Culture LC,30987081,CDM,309,RC,87081,CPT,,,Outpatient,,,64,,,,80,,51.2,percent of total billed charges,,,,50,11.98,fee schedule,,,77.7,,49.73,percent of total billed charges,,,95,,60.8,percent of total billed charges,,,60,,38.4,percent of total billed charges,,38.4,60.8,
Strep Gp B Culture+Rflx LC,30987081,CDM,309,RC,87081,CPT,,,Outpatient,,,45,,,,80,,36,percent of total billed charges,,,,50,11.98,fee schedule,,,77.7,,34.97,percent of total billed charges,,,95,,42.75,percent of total billed charges,,,60,,27,percent of total billed charges,,27,42.75,
87081 Culture screen only LC,30987081,CDM,309,RC,87081,CPT,,,Inpatient,,,63,,,,80,,50.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,48.95,percent of total billed charges,,,95,,59.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,59.85,
Beta Strep Gp A Culture LC,30987081,CDM,309,RC,87081,CPT,,,Inpatient,,,64,,,,80,,51.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,49.73,percent of total billed charges,,,95,,60.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,60.8,
Strep Gp B Culture+Rflx LC,30987081,CDM,309,RC,87081,CPT,,,Inpatient,,,45,,,,80,,36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,34.97,percent of total billed charges,,,95,,42.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,42.75,
Fungus/Mycology Culture - LC,30987101,CDM,309,RC,87101,CPT,,,Outpatient,,,102,,,,80,,81.6,percent of total billed charges,,,,50,12.08,fee schedule,,,77.7,,79.25,percent of total billed charges,,,95,,96.9,percent of total billed charges,,,60,,61.2,percent of total billed charges,,61.2,96.9,
Fungus/Mycology Culture - LC,30987101,CDM,309,RC,87101,CPT,,,Inpatient,,,102,,,,80,,81.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,79.25,percent of total billed charges,,,95,,96.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,96.9,
87116 Mycobacteria culture LC,30987116,CDM,309,RC,87116,CPT,,,Outpatient,,,114,,,,80,,91.2,percent of total billed charges,,,,50,23.95,fee schedule,,,77.7,,88.58,percent of total billed charges,,,95,,108.3,percent of total billed charges,,,60,,68.4,percent of total billed charges,,68.4,108.3,
AFB/Mycobacteria Culture - LC,30987116,CDM,309,RC,87116,CPT,,,Outpatient,,,114,,,,80,,91.2,percent of total billed charges,,,,50,23.95,fee schedule,,,77.7,,88.58,percent of total billed charges,,,95,,108.3,percent of total billed charges,,,60,,68.4,percent of total billed charges,,68.4,108.3,
Acid Fast Smear+Culture LC,30987116,CDM,309,RC,87116,CPT,,,Outpatient,,,114,,,,80,,91.2,percent of total billed charges,,,,50,23.95,fee schedule,,,77.7,,88.58,percent of total billed charges,,,95,,108.3,percent of total billed charges,,,60,,68.4,percent of total billed charges,,68.4,108.3,
87116 Mycobacteria culture LC,30987116,CDM,309,RC,87116,CPT,,,Inpatient,,,114,,,,80,,91.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,88.58,percent of total billed charges,,,95,,108.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,108.3,
AFB/Mycobacteria Culture - LC,30987116,CDM,309,RC,87116,CPT,,,Inpatient,,,114,,,,80,,91.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,88.58,percent of total billed charges,,,95,,108.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,108.3,
Acid Fast Smear+Culture LC,30987116,CDM,309,RC,87116,CPT,,,Inpatient,,,114,,,,80,,91.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,88.58,percent of total billed charges,,,95,,108.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,108.3,
87177 Ova & Parasites,30987177,CDM,309,RC,87177,CPT,,,Outpatient,,,70,,,,80,,56,percent of total billed charges,,,,50,15.71,fee schedule,,,77.7,,54.39,percent of total billed charges,,,95,,66.5,percent of total billed charges,,,60,,42,percent of total billed charges,,42,66.5,
87177 Ova & Parasites,30987177,CDM,309,RC,87177,CPT,,,Inpatient,,,70,,,,80,,56,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,54.39,percent of total billed charges,,,95,,66.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,66.5,
87186 ID and antibiotic susceptibility - LC,30987186,CDM,309,RC,87186,CPT,,,Outpatient,,,65,,,,80,,52,percent of total billed charges,,,,50,16.47,fee schedule,,,77.7,,50.51,percent of total billed charges,,,95,,61.75,percent of total billed charges,,,60,,39,percent of total billed charges,,39,61.75,
87186 ID and antibiotic susceptibility - LC,30987186,CDM,309,RC,87186,CPT,,,Inpatient,,,65,,,,80,,52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,50.51,percent of total billed charges,,,95,,61.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,61.75,
"87205 Smear, primary source with interpretation; Gram or Giemsa stain",30987205,CDM,309,RC,87205,CPT,,,Outpatient,,,45,,,,80,,36,percent of total billed charges,,,,50,7.27,fee schedule,,,77.7,,34.97,percent of total billed charges,,,95,,42.75,percent of total billed charges,,,60,,27,percent of total billed charges,,27,42.75,
"87205 Smear, primary source with interpretation; Gram or Giemsa stain",30987205,CDM,309,RC,87205,CPT,,,Outpatient,,,45,,,,80,,36,percent of total billed charges,,,,50,7.27,fee schedule,,,77.7,,34.97,percent of total billed charges,,,95,,42.75,percent of total billed charges,,,60,,27,percent of total billed charges,,27,42.75,
"Eosinophil, Urine - LC",30987205,CDM,309,RC,87205,CPT,,,Outpatient,,,45,,,,80,,36,percent of total billed charges,,,,50,7.27,fee schedule,,,77.7,,34.97,percent of total billed charges,,,95,,42.75,percent of total billed charges,,,60,,27,percent of total billed charges,,27,42.75,
Gram Stain Evaluation w/ Sputum Culture Reflex LC,30987205,CDM,309,RC,87205,CPT,,,Outpatient,,,45,,,,80,,36,percent of total billed charges,,,,50,7.27,fee schedule,,,77.7,,34.97,percent of total billed charges,,,95,,42.75,percent of total billed charges,,,60,,27,percent of total billed charges,,27,42.75,
Gram Stain/Body Fluid Culture LC,30987205,CDM,309,RC,87205,CPT,,,Outpatient,,,45,,,,80,,36,percent of total billed charges,,,,50,7.27,fee schedule,,,77.7,,34.97,percent of total billed charges,,,95,,42.75,percent of total billed charges,,,60,,27,percent of total billed charges,,27,42.75,
"87205 Smear, primary source with interpretation; Gram or Giemsa stain",30987205,CDM,309,RC,87205,CPT,,,Inpatient,,,45,,,,80,,36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,34.97,percent of total billed charges,,,95,,42.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,42.75,
"87205 Smear, primary source with interpretation; Gram or Giemsa stain",30987205,CDM,309,RC,87205,CPT,,,Inpatient,,,45,,,,80,,36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,34.97,percent of total billed charges,,,95,,42.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,42.75,
"Eosinophil, Urine - LC",30987205,CDM,309,RC,87205,CPT,,,Inpatient,,,45,,,,80,,36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,34.97,percent of total billed charges,,,95,,42.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,42.75,
Gram Stain Evaluation w/ Sputum Culture Reflex LC,30987205,CDM,309,RC,87205,CPT,,,Inpatient,,,45,,,,80,,36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,34.97,percent of total billed charges,,,95,,42.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,42.75,
Gram Stain/Body Fluid Culture LC,30987205,CDM,309,RC,87205,CPT,,,Inpatient,,,45,,,,80,,36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,34.97,percent of total billed charges,,,95,,42.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,42.75,
87206 Smear fluorescent/acid stain LC,30987206,CDM,309,RC,87206,CPT,,,Outpatient,,,85,,,,80,,68,percent of total billed charges,,,,50,15.36,fee schedule,,,77.7,,66.05,percent of total billed charges,,,95,,80.75,percent of total billed charges,,,60,,51,percent of total billed charges,,51,80.75,
Fungus Stain LC,30987206,CDM,309,RC,87206,CPT,,,Outpatient,,,85,,,,80,,68,percent of total billed charges,,,,50,15.36,fee schedule,,,77.7,,66.05,percent of total billed charges,,,95,,80.75,percent of total billed charges,,,60,,51,percent of total billed charges,,51,80.75,
87206 Smear fluorescent/acid stain LC,30987206,CDM,309,RC,87206,CPT,,,Inpatient,,,85,,,,80,,68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,66.05,percent of total billed charges,,,95,,80.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,80.75,
Fungus Stain LC,30987206,CDM,309,RC,87206,CPT,,,Inpatient,,,85,,,,80,,68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,66.05,percent of total billed charges,,,95,,80.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,80.75,
87209 Smear complex stain LC,30987209,CDM,309,RC,87209,CPT,,,Outpatient,,,108,,,,80,,86.4,percent of total billed charges,,,,50,19.29,fee schedule,,,77.7,,83.92,percent of total billed charges,,,95,,102.6,percent of total billed charges,,,60,,64.8,percent of total billed charges,,64.8,102.6,
87209 Smear complex stain LC,30987209,CDM,309,RC,87209,CPT,,,Inpatient,,,108,,,,80,,86.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,83.92,percent of total billed charges,,,95,,102.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,102.6,
HSV Culture and Typing LC,30987255,CDM,309,RC,87255,CPT,,,Outpatient,,,218,,,,80,,174.4,percent of total billed charges,,,,50,40.27,fee schedule,,,77.7,,169.39,percent of total billed charges,,,95,,207.1,percent of total billed charges,,,60,,130.8,percent of total billed charges,,130.8,207.1,
HSV Culture and Typing LC,30987255,CDM,309,RC,87255,CPT,,,Inpatient,,,218,,,,80,,174.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,169.39,percent of total billed charges,,,95,,207.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,207.1,
Aspergillus Galactomannan Anitgen Detection - LC,30987305,CDM,309,RC,87305,CPT,,,Outpatient,,,164,,,,80,,131.2,percent of total billed charges,,,,50,12.87,fee schedule,,,77.7,,127.43,percent of total billed charges,,,95,,155.8,percent of total billed charges,,,60,,98.4,percent of total billed charges,,98.4,155.8,
Aspergillus Galactomannan Anitgen Detection - LC,30987305,CDM,309,RC,87305,CPT,,,Inpatient,,,164,,,,80,,131.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,127.43,percent of total billed charges,,,95,,155.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,155.8,
"Cryptosporidium, Direct Detection EIA - LC",30987328,CDM,309,RC,87328,CPT,,,Outpatient,,,165,,,,80,,132,percent of total billed charges,,,,50,30.18,fee schedule,,,77.7,,128.21,percent of total billed charges,,,95,,156.75,percent of total billed charges,,,60,,99,percent of total billed charges,,99,156.75,
"Cryptosporidium, Direct Detection EIA - LC",30987328,CDM,309,RC,87328,CPT,,,Inpatient,,,165,,,,80,,132,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,128.21,percent of total billed charges,,,95,,156.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,156.75,
"Giardia Lamblia Ag, EIA - LC",30987329,CDM,309,RC,87329,CPT,,,Outpatient,,,197,,,,80,,157.6,percent of total billed charges,,,,50,30.18,fee schedule,,,77.7,,153.07,percent of total billed charges,,,95,,187.15,percent of total billed charges,,,60,,118.2,percent of total billed charges,,118.2,187.15,
"Giardia lamblia, EIA and Ova & Parasites (O&P) Exam - LC",30987329,CDM,309,RC,87329,CPT,,,Outpatient,,,197,,,,80,,157.6,percent of total billed charges,,,,50,30.18,fee schedule,,,77.7,,153.07,percent of total billed charges,,,95,,187.15,percent of total billed charges,,,60,,118.2,percent of total billed charges,,118.2,187.15,
"Giardia Lamblia Ag, EIA - LC",30987329,CDM,309,RC,87329,CPT,,,Inpatient,,,197,,,,80,,157.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,153.07,percent of total billed charges,,,95,,187.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,187.15,
"Giardia lamblia, EIA and Ova & Parasites (O&P) Exam - LC",30987329,CDM,309,RC,87329,CPT,,,Inpatient,,,197,,,,80,,157.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,153.07,percent of total billed charges,,,95,,187.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,187.15,
87340 Hepatitis b surface AG IA LC,30987340,CDM,309,RC,87340,CPT,,,Outpatient,,,114,,,,80,,91.2,percent of total billed charges,,,,50,12.31,fee schedule,,,77.7,,88.58,percent of total billed charges,,,95,,108.3,percent of total billed charges,,,60,,68.4,percent of total billed charges,,68.4,108.3,
87340 Hepatitis b surface AG IA LC,30987340,CDM,309,RC,87340,CPT,,,Inpatient,,,114,,,,80,,91.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,88.58,percent of total billed charges,,,95,,108.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,108.3,
Hep Be Ag LC,30987350,CDM,309,RC,87350,CPT,,,Outpatient,,,132,,,,80,,105.6,percent of total billed charges,,,,50,21.69,fee schedule,,,77.7,,102.56,percent of total billed charges,,,95,,125.4,percent of total billed charges,,,60,,79.2,percent of total billed charges,,79.2,125.4,
Hep Be Ag LC,30987350,CDM,309,RC,87350,CPT,,,Inpatient,,,132,,,,80,,105.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,102.56,percent of total billed charges,,,95,,125.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,125.4,
87427 Shiga-like toxin AG IA LC,30987427,CDM,309,RC,87427,CPT,,,Outpatient,,,105,,,,80,,84,percent of total billed charges,,,,50,27.42,fee schedule,,,77.7,,81.59,percent of total billed charges,,,95,,99.75,percent of total billed charges,,,60,,63,percent of total billed charges,,63,99.75,
87427 Shiga-like toxin AG IA LC,30987427,CDM,309,RC,87427,CPT,,,Inpatient,,,105,,,,80,,84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,81.59,percent of total billed charges,,,95,,99.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,99.75,
"Ct Ng M genitalium NAA, Urine - LC",30987491,CDM,309,RC,87491,CPT,,,Outpatient,,,131,,,,80,,104.8,percent of total billed charges,,,,50,37.66,fee schedule,,,77.7,,101.79,percent of total billed charges,,,95,,124.45,percent of total billed charges,,,60,,78.6,percent of total billed charges,,78.6,124.45,
"Ct, Ng, Trich vag by NAA - LC",30987491,CDM,309,RC,87491,CPT,,,Outpatient,,,131,,,,80,,104.8,percent of total billed charges,,,,50,37.66,fee schedule,,,77.7,,101.79,percent of total billed charges,,,95,,124.45,percent of total billed charges,,,60,,78.6,percent of total billed charges,,78.6,124.45,
"Ct Ng M genitalium NAA, Urine - LC",30987491,CDM,309,RC,87491,CPT,,,Inpatient,,,131,,,,80,,104.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,101.79,percent of total billed charges,,,95,,124.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,124.45,
"Ct, Ng, Trich vag by NAA - LC",30987491,CDM,309,RC,87491,CPT,,,Inpatient,,,131,,,,80,,104.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,101.79,percent of total billed charges,,,95,,124.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,124.45,
"CMV PCR, Qualitative LC",30987496,CDM,309,RC,87496,CPT,,,Outpatient,,,125,,,,80,,100,percent of total billed charges,,,,50,37.66,fee schedule,,,77.7,,97.13,percent of total billed charges,,,95,,118.75,percent of total billed charges,,,60,,75,percent of total billed charges,,75,118.75,
"CMV PCR, Qualitative LC",30987496,CDM,309,RC,87496,CPT,,,Inpatient,,,125,,,,80,,100,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,97.13,percent of total billed charges,,,95,,118.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,118.75,
CMV Quant DNA PCR (Plasma) - LC,30987497,CDM,309,RC,87497,CPT,,,Outpatient,,,330,,,,80,,264,percent of total billed charges,,,,50,45.96,fee schedule,,,77.7,,256.41,percent of total billed charges,,,95,,313.5,percent of total billed charges,,,60,,198,percent of total billed charges,,198,313.5,
CMV Quant DNA PCR (Plasma) - LC,30987497,CDM,309,RC,87497,CPT,,,Inpatient,,,330,,,,80,,264,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,256.41,percent of total billed charges,,,95,,313.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,313.5,
"HCV RT-PCR, Quant (Graph) LC",30987506,CDM,309,RC,87506,CPT,,,Outpatient,,,625,,,,80,,500,percent of total billed charges,,,,50,232.87,fee schedule,,,77.7,,485.63,percent of total billed charges,,,95,,593.75,percent of total billed charges,,,60,,375,percent of total billed charges,,375,593.75,
"HCV RT-PCR, Quant (Graph) LC",30987506,CDM,309,RC,87506,CPT,,,Inpatient,,,625,,,,80,,500,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,485.63,percent of total billed charges,,,95,,593.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,593.75,
"Gastrointestinal Profile, Stool, PCR - LC",30987507,CDM,309,RC,87507,CPT,,,Outpatient,,,1300,,,,80,,1040,percent of total billed charges,,,,50,454.74,fee schedule,,,77.7,,1010.1,percent of total billed charges,,,95,,1235,percent of total billed charges,,,60,,780,percent of total billed charges,,780,1235,
"Gastrointestinal Profile, Stool, PCR - LC",30987507,CDM,309,RC,87507,CPT,,,Inpatient,,,1300,,,,80,,1040,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1010.1,percent of total billed charges,,,95,,1235,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1235,
"HBV Real-Time PCR, Quant - LC",30987517,CDM,309,RC,87517,CPT,,,Outpatient,,,350,,,,80,,280,percent of total billed charges,,,,50,114.84,fee schedule,,,77.7,,271.95,percent of total billed charges,,,95,,332.5,percent of total billed charges,,,60,,210,percent of total billed charges,,210,332.5,
"HBV, Quant, DNA Real-Time PCR (Graphical) - LC",30987517,CDM,309,RC,87517,CPT,,,Outpatient,,,300,,,,80,,240,percent of total billed charges,,,,50,114.84,fee schedule,,,77.7,,233.1,percent of total billed charges,,,95,,285,percent of total billed charges,,,60,,180,percent of total billed charges,,180,285,
"HBV Real-Time PCR, Quant - LC",30987517,CDM,309,RC,87517,CPT,,,Inpatient,,,350,,,,80,,280,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,271.95,percent of total billed charges,,,95,,332.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,332.5,
"HBV, Quant, DNA Real-Time PCR (Graphical) - LC",30987517,CDM,309,RC,87517,CPT,,,Inpatient,,,300,,,,80,,240,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,233.1,percent of total billed charges,,,95,,285,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,285,
"HCV RT-PCR, Quant (Non-Graph) LC",30987522,CDM,309,RC,87522,CPT,,,Outpatient,,,135,,,,80,,108,percent of total billed charges,,,,50,45.96,fee schedule,,,77.7,,104.9,percent of total billed charges,,,95,,128.25,percent of total billed charges,,,60,,81,percent of total billed charges,,81,128.25,
"HCV RT-PCR, Quant (Non-Graph) LC",30987522,CDM,309,RC,87522,CPT,,,Inpatient,,,135,,,,80,,108,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,104.9,percent of total billed charges,,,95,,128.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,128.25,
87529 IADNA HERPES SOMPLX VIRUS AMPLIFIED PROBE TQ LC,30987529,CDM,309,RC,87529,CPT,,,Outpatient,,,135,,,,80,,108,percent of total billed charges,,,,50,37.66,fee schedule,,,77.7,,104.9,percent of total billed charges,,,95,,128.25,percent of total billed charges,,,60,,81,percent of total billed charges,,81,128.25,
HSV 1/2 PCR LC,30987529,CDM,309,RC,87529,CPT,,,Outpatient,,,135,,,,80,,108,percent of total billed charges,,,,50,37.66,fee schedule,,,77.7,,104.9,percent of total billed charges,,,95,,128.25,percent of total billed charges,,,60,,81,percent of total billed charges,,81,128.25,
87529 IADNA HERPES SOMPLX VIRUS AMPLIFIED PROBE TQ LC,30987529,CDM,309,RC,87529,CPT,,,Inpatient,,,135,,,,80,,108,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,104.9,percent of total billed charges,,,95,,128.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,128.25,
HSV 1/2 PCR LC,30987529,CDM,309,RC,87529,CPT,,,Inpatient,,,135,,,,80,,108,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,104.9,percent of total billed charges,,,95,,128.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,128.25,
"HIV-1 RNA, Quant, Real-time PCR (Nongraphical) - LC",30987536,CDM,309,RC,87536,CPT,,,Outpatient,,,173,,,,80,,138.4,percent of total billed charges,,,,50,91.3,fee schedule,,,77.7,,134.42,percent of total billed charges,,,95,,164.35,percent of total billed charges,,,60,,103.8,percent of total billed charges,,103.8,164.35,
"HIV-1 RNA, Quant, Real-time PCR (Nongraphical) - LC",30987536,CDM,309,RC,87536,CPT,,,Inpatient,,,173,,,,80,,138.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,134.42,percent of total billed charges,,,95,,164.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,164.35,
87591 N.gonorrhoeae dna amp prob LC,30987591,CDM,309,RC,87591,CPT,,,Outpatient,,,129,,,,80,,103.2,percent of total billed charges,,,,50,37.66,fee schedule,,,77.7,,100.23,percent of total billed charges,,,95,,122.55,percent of total billed charges,,,60,,77.4,percent of total billed charges,,77.4,122.55,
87591 N.gonorrhoeae dna amp prob LC,30987591,CDM,309,RC,87591,CPT,,,Inpatient,,,129,,,,80,,103.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,100.23,percent of total billed charges,,,95,,122.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,122.55,
HPV cobas high-risk/16/18 - LC,30987624,CDM,309,RC,87624,CPT,,,Outpatient,,,125,,,,80,,100,percent of total billed charges,,,,50,30.48,fee schedule,,,77.7,,97.13,percent of total billed charges,,,95,,118.75,percent of total billed charges,,,60,,75,percent of total billed charges,,75,118.75,
HPV cobas high-risk/16/18 - LC,30987624,CDM,309,RC,87624,CPT,,,Inpatient,,,125,,,,80,,100,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,97.13,percent of total billed charges,,,95,,118.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,118.75,
87661 Trichomonas Vaginalis Amp,30987661,CDM,309,RC,87661,CPT,,,Outpatient,,,75,,,,80,,60,percent of total billed charges,,,,50,47.75,fee schedule,,,77.7,,58.28,percent of total billed charges,,,95,,71.25,percent of total billed charges,,,60,,45,percent of total billed charges,,45,71.25,
87661 Trichomonas Vaginalis Amp,30987661,CDM,309,RC,87661,CPT,,,Inpatient,,,75,,,,80,,60,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,58.28,percent of total billed charges,,,95,,71.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,71.25,
87798 Detect agent nos DNA amp LC,30987798,CDM,309,RC,87798,CPT,,,Outpatient,,,144,,,,80,,115.2,percent of total billed charges,,,,50,92.82,fee schedule,,,77.7,,111.89,percent of total billed charges,,,95,,136.8,percent of total billed charges,,,60,,86.4,percent of total billed charges,,86.4,136.8,
"87798 Mycoplasma Genitalium, NAA",30987798,CDM,309,RC,87798,CPT,,,Outpatient,,,144,,,,80,,115.2,percent of total billed charges,,,,50,92.82,fee schedule,,,77.7,,111.89,percent of total billed charges,,,95,,136.8,percent of total billed charges,,,60,,86.4,percent of total billed charges,,86.4,136.8,
"Bacterial Vaginosis, NAA - LC",30987798,CDM,309,RC,87798,CPT,,,Outpatient,,,144,,,,80,,115.2,percent of total billed charges,,,,50,92.82,fee schedule,,,77.7,,111.89,percent of total billed charges,,,95,,136.8,percent of total billed charges,,,60,,86.4,percent of total billed charges,,86.4,136.8,
87798 Detect agent nos DNA amp LC,30987798,CDM,309,RC,87798,CPT,,,Inpatient,,,144,,,,80,,115.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,111.89,percent of total billed charges,,,95,,136.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,136.8,
"87798 Mycoplasma Genitalium, NAA",30987798,CDM,309,RC,87798,CPT,,,Inpatient,,,144,,,,80,,115.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,111.89,percent of total billed charges,,,95,,136.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,136.8,
"Bacterial Vaginosis, NAA - LC",30987798,CDM,309,RC,87798,CPT,,,Inpatient,,,144,,,,80,,115.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,111.89,percent of total billed charges,,,95,,136.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,136.8,
BK Virus Quant PCR (Plasma/Serum) - LC,30987799,CDM,309,RC,87799,CPT,,,Outpatient,,,581,,,,80,,464.8,percent of total billed charges,,,,50,125.79,fee schedule,,,77.7,,451.44,percent of total billed charges,,,95,,551.95,percent of total billed charges,,,60,,348.6,percent of total billed charges,,348.6,551.95,
BK Virus Quant PCR (Urine) - LC,30987799,CDM,309,RC,87799,CPT,,,Outpatient,,,581,,,,80,,464.8,percent of total billed charges,,,,50,125.79,fee schedule,,,77.7,,451.44,percent of total billed charges,,,95,,551.95,percent of total billed charges,,,60,,348.6,percent of total billed charges,,348.6,551.95,
"Epstein-Barr DNA Quant, PCR - LC",30987799,CDM,309,RC,87799,CPT,,,Outpatient,,,581,,,,80,,464.8,percent of total billed charges,,,,50,125.79,fee schedule,,,77.7,,451.44,percent of total billed charges,,,95,,551.95,percent of total billed charges,,,60,,348.6,percent of total billed charges,,348.6,551.95,
BK Virus Quant PCR (Plasma/Serum) - LC,30987799,CDM,309,RC,87799,CPT,,,Inpatient,,,581,,,,80,,464.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,451.44,percent of total billed charges,,,95,,551.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,551.95,
BK Virus Quant PCR (Urine) - LC,30987799,CDM,309,RC,87799,CPT,,,Inpatient,,,581,,,,80,,464.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,451.44,percent of total billed charges,,,95,,551.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,551.95,
"Epstein-Barr DNA Quant, PCR - LC",30987799,CDM,309,RC,87799,CPT,,,Inpatient,,,581,,,,80,,464.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,451.44,percent of total billed charges,,,95,,551.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,551.95,
"Cryptococcus Antigen, CSF LC",30987899,CDM,309,RC,87899,CPT,,,Outpatient,,,157,,,,80,,125.6,percent of total billed charges,,,,50,27.42,fee schedule,,,77.7,,121.99,percent of total billed charges,,,95,,149.15,percent of total billed charges,,,60,,94.2,percent of total billed charges,,94.2,149.15,
"Cryptococcus Antigen, CSF LC",30987899,CDM,309,RC,87899,CPT,,,Inpatient,,,157,,,,80,,125.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,121.99,percent of total billed charges,,,95,,149.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,149.15,
HCV Genotyping Non Reflex - LC,30987902,CDM,309,RC,87902,CPT,,,Outpatient,,,269.5,,,,80,,215.6,percent of total billed charges,,,,50,276.22,fee schedule,,,77.7,,209.4,percent of total billed charges,,,95,,256.03,percent of total billed charges,,,60,,161.7,percent of total billed charges,,161.7,256.03,
HCV Genotyping Non Reflex - LC,30987902,CDM,309,RC,87902,CPT,,,Inpatient,,,269.5,,,,80,,215.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,209.4,percent of total billed charges,,,95,,256.03,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,256.03,
"Cell Count, CSF LC",30989051,CDM,309,RC,89051,CPT,,,Outpatient,,,54,,,,80,,43.2,percent of total billed charges,,,,50,20.73,fee schedule,,,77.7,,41.96,percent of total billed charges,,,95,,51.3,percent of total billed charges,,,60,,32.4,percent of total billed charges,,32.4,51.3,
"Cell Ct, Serous Fluid LC",30989051,CDM,309,RC,89051,CPT,,,Outpatient,,,54,,,,80,,43.2,percent of total billed charges,,,,50,20.73,fee schedule,,,77.7,,41.96,percent of total billed charges,,,95,,51.3,percent of total billed charges,,,60,,32.4,percent of total billed charges,,32.4,51.3,
"Cell Ct, Synovial w/o Crystals LC",30989051,CDM,309,RC,89051,CPT,,,Outpatient,,,54,,,,80,,43.2,percent of total billed charges,,,,50,20.73,fee schedule,,,77.7,,41.96,percent of total billed charges,,,95,,51.3,percent of total billed charges,,,60,,32.4,percent of total billed charges,,32.4,51.3,
"Cell Count, CSF LC",30989051,CDM,309,RC,89051,CPT,,,Inpatient,,,54,,,,80,,43.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,41.96,percent of total billed charges,,,95,,51.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,51.3,
"Cell Ct, Serous Fluid LC",30989051,CDM,309,RC,89051,CPT,,,Inpatient,,,54,,,,80,,43.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,41.96,percent of total billed charges,,,95,,51.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,51.3,
"Cell Ct, Synovial w/o Crystals LC",30989051,CDM,309,RC,89051,CPT,,,Inpatient,,,54,,,,80,,43.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,41.96,percent of total billed charges,,,95,,51.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,51.3,
"Cell Ct, Synovial w/Crystals LC",30989060,CDM,309,RC,89060,CPT,,,Outpatient,,,194,,,,80,,155.2,percent of total billed charges,,,,50,36.74,fee schedule,,,77.7,,150.74,percent of total billed charges,,,95,,184.3,percent of total billed charges,,,60,,116.4,percent of total billed charges,,116.4,184.3,
"Crystals, Synovial/Joint Fluid - LC",30989060,CDM,309,RC,89060,CPT,,,Outpatient,,,194,,,,80,,155.2,percent of total billed charges,,,,50,36.74,fee schedule,,,77.7,,150.74,percent of total billed charges,,,95,,184.3,percent of total billed charges,,,60,,116.4,percent of total billed charges,,116.4,184.3,
"Cell Ct, Synovial w/Crystals LC",30989060,CDM,309,RC,89060,CPT,,,Inpatient,,,194,,,,80,,155.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,150.74,percent of total billed charges,,,95,,184.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,184.3,
"Crystals, Synovial/Joint Fluid - LC",30989060,CDM,309,RC,89060,CPT,,,Inpatient,,,194,,,,80,,155.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,150.74,percent of total billed charges,,,95,,184.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,184.3,
"Fecal Fat/Muscle Fibers, Qual LC",30989160,CDM,309,RC,89160,CPT,,,Outpatient,,,230,,,,80,,184,percent of total billed charges,,,,50,32.52,fee schedule,,,77.7,,178.71,percent of total billed charges,,,95,,218.5,percent of total billed charges,,,60,,138,percent of total billed charges,,138,218.5,
"Fecal Fat/Muscle Fibers, Qual LC",30989160,CDM,309,RC,89160,CPT,,,Inpatient,,,230,,,,80,,184,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,178.71,percent of total billed charges,,,95,,218.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,218.5,
Factor V Leiden Reflex to R2 - LC,31081241,CDM,310,RC,81241,CPT,,,Outpatient,,,275,,,,80,,220,percent of total billed charges,,,,50,87.57,fee schedule,,,77.7,,213.68,percent of total billed charges,,,95,,261.25,percent of total billed charges,,,60,,165,percent of total billed charges,,165,261.25,
Factor V Leiden Reflex to R2 - LC,31081241,CDM,310,RC,81241,CPT,,,Inpatient,,,275,,,,80,,220,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,213.68,percent of total billed charges,,,95,,261.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,261.25,
87505 GASTROINTESTINAL PATHOGEN 3-5 TARGETS,31087505,CDM,310,RC,87505,CPT,,,Outpatient,,,765,,,,80,,612,percent of total billed charges,,,,50,139.97,fee schedule,,,77.7,,594.41,percent of total billed charges,,,95,,726.75,percent of total billed charges,,,60,,459,percent of total billed charges,,459,726.75,
87505 GASTROINTESTINAL PATHOGEN 3-5 TARGETS,31087505,CDM,310,RC,87505,CPT,,,Inpatient,,,765,,,,80,,612,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,594.41,percent of total billed charges,,,95,,726.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,726.75,
"88230 TISSUE CULTURE, LYMPHOCYTE CHROMOSOME",31088230,CDM,310,RC,88230,CPT,,,Outpatient,,,1118,,,,80,,894.4,percent of total billed charges,,,,50,294.32,fee schedule,,,77.7,,868.69,percent of total billed charges,,,95,,1062.1,percent of total billed charges,,,60,,670.8,percent of total billed charges,,670.8,1062.1,
"88230 TISSUE CULTURE, LYMPHOCYTE CHROMOSOME",31088230,CDM,310,RC,88230,CPT,,,Inpatient,,,1118,,,,80,,894.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,868.69,percent of total billed charges,,,95,,1062.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1062.1,
88262 CHROMOSOME ANALYSIS 15-20,31088262,CDM,310,RC,88262,CPT,,,Outpatient,,,997,,,,80,,797.6,percent of total billed charges,,,,50,262.27,fee schedule,,,77.7,,774.67,percent of total billed charges,,,95,,947.15,percent of total billed charges,,,60,,598.2,percent of total billed charges,,598.2,947.15,
"Chromosome, Blood, Routine LC",31088262,CDM,310,RC,88262,CPT,,,Outpatient,,,850,,,,80,,680,percent of total billed charges,,,,50,262.27,fee schedule,,,77.7,,660.45,percent of total billed charges,,,95,,807.5,percent of total billed charges,,,60,,510,percent of total billed charges,,510,807.5,
88262 CHROMOSOME ANALYSIS 15-20,31088262,CDM,310,RC,88262,CPT,,,Inpatient,,,997,,,,80,,797.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,774.67,percent of total billed charges,,,95,,947.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,947.15,
"Chromosome, Blood, Routine LC",31088262,CDM,310,RC,88262,CPT,,,Inpatient,,,850,,,,80,,680,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,660.45,percent of total billed charges,,,95,,807.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,807.5,
88280 CHROMOSOME ANALYSIS ADDL KARYOTYPE EACH STUDY,31088280,CDM,310,RC,88280,CPT,,,Outpatient,,,487,,,,80,,389.6,percent of total billed charges,,,,50,104.83,fee schedule,,,77.7,,378.4,percent of total billed charges,,,95,,462.65,percent of total billed charges,,,60,,292.2,percent of total billed charges,,292.2,462.65,
88280 CHROMOSOME ANALYSIS ADDL KARYOTYPE EACH STUDY,31088280,CDM,310,RC,88280,CPT,,,Inpatient,,,487,,,,80,,389.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,378.4,percent of total billed charges,,,95,,462.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,462.65,
88300 SURG PATH LEVEL I,31088300,CDM,310,RC,88300,CPT,,,Outpatient,,,135,,,,80,,108,percent of total billed charges,,,,50,15.91,fee schedule,,,77.7,,104.9,percent of total billed charges,,,95,,128.25,percent of total billed charges,,,60,,81,percent of total billed charges,,81,128.25,
88300 SURG PATH LEVEL I,31088300,CDM,310,RC,88300,CPT,,,Inpatient,,,135,,,,80,,108,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,104.9,percent of total billed charges,,,95,,128.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,128.25,
88302 SURG PATH LEVEL II,31088302,CDM,310,RC,88302,CPT,,,Outpatient,,,137,,,,80,,109.6,percent of total billed charges,,,,50,40.29,fee schedule,,,77.7,,106.45,percent of total billed charges,,,95,,130.15,percent of total billed charges,,,60,,82.2,percent of total billed charges,,82.2,130.15,
88302 SURG PATH LEVEL II,31088302,CDM,310,RC,88302,CPT,,,Inpatient,,,137,,,,80,,109.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,106.45,percent of total billed charges,,,95,,130.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,130.15,
88304 SURG PATH LEVEL III,31088304,CDM,310,RC,88304,CPT,,,Outpatient,,,198,,,,80,,158.4,percent of total billed charges,,,,50,58.14,fee schedule,,,77.7,,153.85,percent of total billed charges,,,95,,188.1,percent of total billed charges,,,60,,118.8,percent of total billed charges,,118.8,188.1,
88304 SURG PATH LEVEL III,31088304,CDM,310,RC,88304,CPT,,,Inpatient,,,198,,,,80,,158.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,153.85,percent of total billed charges,,,95,,188.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,188.1,
88305 SURG PATH LEVEL IV,31088305,CDM,310,RC,88305,CPT,,,Outpatient,,,333,,,,80,,266.4,percent of total billed charges,,,,50,97.81,fee schedule,,,77.7,,258.74,percent of total billed charges,,,95,,316.35,percent of total billed charges,,,60,,199.8,percent of total billed charges,,199.8,316.35,
88305 SURG PATH LEVEL IV,31088305,CDM,310,RC,88305,CPT,,,Inpatient,,,333,,,,80,,266.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,258.74,percent of total billed charges,,,95,,316.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,316.35,
88307 SURG PATH LEVEL V,31088307,CDM,310,RC,88307,CPT,,,Outpatient,,,556,,,,80,,444.8,percent of total billed charges,,,,50,135.91,fee schedule,,,77.7,,432.01,percent of total billed charges,,,95,,528.2,percent of total billed charges,,,60,,333.6,percent of total billed charges,,333.6,528.2,
88307 SURG PATH LEVEL V,31088307,CDM,310,RC,88307,CPT,,,Inpatient,,,556,,,,80,,444.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,432.01,percent of total billed charges,,,95,,528.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,528.2,
88312 SPECIAL STAINS GROUP 1,31088312,CDM,310,RC,88312,CPT,,,Outpatient,,,141,,,,80,,112.8,percent of total billed charges,,,,50,38.84,fee schedule,,,77.7,,109.56,percent of total billed charges,,,95,,133.95,percent of total billed charges,,,60,,84.6,percent of total billed charges,,84.6,133.95,
88312 SPECIAL STAINS GROUP 1,31088312,CDM,310,RC,88312,CPT,,,Inpatient,,,141,,,,80,,112.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,109.56,percent of total billed charges,,,95,,133.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,133.95,
88313 SPECIAL STAINS GROUP 2,31088313,CDM,310,RC,88313,CPT,,,Outpatient,,,103,,,,80,,82.4,percent of total billed charges,,,,50,30.15,fee schedule,,,77.7,,80.03,percent of total billed charges,,,95,,97.85,percent of total billed charges,,,60,,61.8,percent of total billed charges,,61.8,97.85,
88313 SPECIAL STAINS GROUP 2,31088313,CDM,310,RC,88313,CPT,,,Inpatient,,,103,,,,80,,82.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,80.03,percent of total billed charges,,,95,,97.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,97.85,
88341 IMHCHEM/IMCYTCHM EA ADDL SINGLE ANTB STAIN PX,31088341,CDM,310,RC,88341,CPT,,,Outpatient,,,288,,,,80,,230.4,percent of total billed charges,,,,50,143.93,fee schedule,,,77.7,,223.78,percent of total billed charges,,,95,,273.6,percent of total billed charges,,,60,,172.8,percent of total billed charges,,172.8,273.6,
88341 IMHCHEM/IMCYTCHM EA ADDL SINGLE ANTB STAIN PX,31088341,CDM,310,RC,88341,CPT,,,Inpatient,,,288,,,,80,,230.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,223.78,percent of total billed charges,,,95,,273.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,273.6,
88342 SPECIAL STAINS,31088342,CDM,310,RC,88342,CPT,,,Outpatient,,,358,,,,80,,286.4,percent of total billed charges,,,,50,143.93,fee schedule,,,77.7,,278.17,percent of total billed charges,,,95,,340.1,percent of total billed charges,,,60,,214.8,percent of total billed charges,,214.8,340.1,
88342 SPECIAL STAINS,31088342,CDM,310,RC,88342,CPT,,,Inpatient,,,358,,,,80,,286.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,278.17,percent of total billed charges,,,95,,340.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,340.1,
XR Orbits Complete Left,32070030,CDM,320,RC,70030,CPT,,,Outpatient,,,248,,,,80,,198.4,percent of total billed charges,,,,50,41.82,fee schedule,,,77.7,,192.7,percent of total billed charges,,,95,,235.6,percent of total billed charges,,,60,,148.8,percent of total billed charges,,148.8,235.6,
XR Orbits Complete Right,32070030,CDM,320,RC,70030,CPT,,,Outpatient,,,248,,,,80,,198.4,percent of total billed charges,,,,50,41.82,fee schedule,,,77.7,,192.7,percent of total billed charges,,,95,,235.6,percent of total billed charges,,,60,,148.8,percent of total billed charges,,148.8,235.6,
XR Orbits Complete Left,32070030,CDM,320,RC,70030,CPT,,,Inpatient,,,248,,,,80,,198.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,192.7,percent of total billed charges,,,95,,235.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,235.6,
XR Orbits Complete Right,32070030,CDM,320,RC,70030,CPT,,,Inpatient,,,248,,,,80,,198.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,192.7,percent of total billed charges,,,95,,235.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,235.6,
XR Mandible Partial Less Than 4 Views,32070100,CDM,320,RC,70100,CPT,,,Outpatient,,,162,,,,80,,129.6,percent of total billed charges,,,,85,137.7,percent of total billed charges,,,77.7,,125.87,percent of total billed charges,,,95,,153.9,percent of total billed charges,,,60,,97.2,percent of total billed charges,,97.2,153.9,
XR Mandible Partial Less Than 4 Views,32070100,CDM,320,RC,70100,CPT,,,Inpatient,,,162,,,,80,,129.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,125.87,percent of total billed charges,,,95,,153.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,153.9,
XR Mastoids < 3 Views Bilateral,32070130,CDM,320,RC,70130,CPT,,,Outpatient,,,354,,,,80,,283.2,percent of total billed charges,,,,85,300.9,percent of total billed charges,,,77.7,,275.06,percent of total billed charges,,,95,,336.3,percent of total billed charges,,,60,,212.4,percent of total billed charges,,212.4,336.3,
XR Mastoids < 3 Views Bilateral,32070130,CDM,320,RC,70130,CPT,,,Inpatient,,,354,,,,80,,283.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,275.06,percent of total billed charges,,,95,,336.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,336.3,
XR Facial Bones < 3 Views,32070140,CDM,320,RC,70140,CPT,,,Outpatient,,,224,,,,80,,179.2,percent of total billed charges,,,,50,89.67,fee schedule,,,77.7,,174.05,percent of total billed charges,,,95,,212.8,percent of total billed charges,,,60,,134.4,percent of total billed charges,,134.4,212.8,
XR Facial Bones < 3 Views,32070140,CDM,320,RC,70140,CPT,,,Inpatient,,,224,,,,80,,179.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,174.05,percent of total billed charges,,,95,,212.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,212.8,
XR Sinuses Paranasal < 3 Views,32070210,CDM,320,RC,70210,CPT,,,Outpatient,,,239,,,,80,,191.2,percent of total billed charges,,,,50,53.43,fee schedule,,,77.7,,185.7,percent of total billed charges,,,95,,227.05,percent of total billed charges,,,60,,143.4,percent of total billed charges,,143.4,227.05,
XR Sinuses Paranasal < 3 Views,32070210,CDM,320,RC,70210,CPT,,,Inpatient,,,239,,,,80,,191.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,185.7,percent of total billed charges,,,95,,227.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,227.05,
XR TMJ Open and Closed Bilateral,32070330,CDM,320,RC,70330,CPT,,,Outpatient,,,308,,,,80,,246.4,percent of total billed charges,,,,85,261.8,percent of total billed charges,,,77.7,,239.32,percent of total billed charges,,,95,,292.6,percent of total billed charges,,,60,,184.8,percent of total billed charges,,184.8,292.6,
XR TMJ Open and Closed Bilateral,32070330,CDM,320,RC,70330,CPT,,,Inpatient,,,308,,,,80,,246.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,239.32,percent of total billed charges,,,95,,292.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,292.6,
XR Chest Decubitus Bilateral,32071047,CDM,320,RC,71047,CPT,,,Outpatient,,,195,,,,80,,156,percent of total billed charges,,,,50,78.48,fee schedule,,,77.7,,151.52,percent of total billed charges,,,95,,185.25,percent of total billed charges,,,60,,117,percent of total billed charges,,117,185.25,
XR Chest Decubitus Bilateral,32071047,CDM,320,RC,71047,CPT,,,Inpatient,,,195,,,,80,,156,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,151.52,percent of total billed charges,,,95,,185.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,185.25,
XR Ribs 2 Views Right,32071100,CDM,320,RC,71100,CPT,,,Outpatient,,,239,,,,80,,191.2,percent of total billed charges,,,,50,66.9,fee schedule,,,77.7,,185.7,percent of total billed charges,,,95,,227.05,percent of total billed charges,,,60,,143.4,percent of total billed charges,,143.4,227.05,
XR Ribs 2 Views Right,32071100,CDM,320,RC,71100,CPT,,,Inpatient,,,239,,,,80,,191.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,185.7,percent of total billed charges,,,95,,227.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,227.05,
XR Ribs w/ PA Chest Bilateral,32071111,CDM,320,RC,71111,CPT,,,Outpatient,,,372,,,,80,,297.6,percent of total billed charges,,,,50,122.66,fee schedule,,,77.7,,289.04,percent of total billed charges,,,95,,353.4,percent of total billed charges,,,60,,223.2,percent of total billed charges,,223.2,353.4,
XR Ribs w/ PA Chest Bilateral,32071111,CDM,320,RC,71111,CPT,,,Inpatient,,,372,,,,80,,297.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,289.04,percent of total billed charges,,,95,,353.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,353.4,
XR Sternum Minimum 2 Views,32071120,CDM,320,RC,71120,CPT,,,Outpatient,,,196,,,,80,,156.8,percent of total billed charges,,,,50,72.48,fee schedule,,,77.7,,152.29,percent of total billed charges,,,95,,186.2,percent of total billed charges,,,60,,117.6,percent of total billed charges,,117.6,186.2,
XR Sternum Minimum 2 Views,32071120,CDM,320,RC,71120,CPT,,,Inpatient,,,196,,,,80,,156.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,152.29,percent of total billed charges,,,95,,186.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,186.2,
XR Sternoclavicular Joint(s),32071130,CDM,320,RC,71130,CPT,,,Outpatient,,,196,,,,80,,156.8,percent of total billed charges,,,,85,166.6,percent of total billed charges,,,77.7,,152.29,percent of total billed charges,,,95,,186.2,percent of total billed charges,,,60,,117.6,percent of total billed charges,,117.6,186.2,
XR Sternoclavicular Joint(s),32071130,CDM,320,RC,71130,CPT,,,Inpatient,,,196,,,,80,,156.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,152.29,percent of total billed charges,,,95,,186.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,186.2,
XR Sacroiliac Joints 1 or 2 Views,32072200,CDM,320,RC,72200,CPT,,,Outpatient,,,200,,,,80,,160,percent of total billed charges,,,,50,71.09,fee schedule,,,77.7,,155.4,percent of total billed charges,,,95,,190,percent of total billed charges,,,60,,120,percent of total billed charges,,120,190,
XR Sacroiliac Joints 1 or 2 Views,32072200,CDM,320,RC,72200,CPT,,,Inpatient,,,200,,,,80,,160,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,155.4,percent of total billed charges,,,95,,190,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,190,
XR Scapula Left,32073010,CDM,320,RC,73010,CPT,,,Outpatient,,,186,,,,80,,148.8,percent of total billed charges,,,,50,58.54,fee schedule,,,77.7,,144.52,percent of total billed charges,,,95,,176.7,percent of total billed charges,,,60,,111.6,percent of total billed charges,,111.6,176.7,
XR Scapula Right,32073010,CDM,320,RC,73010,CPT,,,Outpatient,,,186,,,,80,,148.8,percent of total billed charges,,,,50,58.54,fee schedule,,,77.7,,144.52,percent of total billed charges,,,95,,176.7,percent of total billed charges,,,60,,111.6,percent of total billed charges,,111.6,176.7,
XR Scapula Left,32073010,CDM,320,RC,73010,CPT,,,Inpatient,,,186,,,,80,,148.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,144.52,percent of total billed charges,,,95,,176.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,176.7,
XR Scapula Right,32073010,CDM,320,RC,73010,CPT,,,Inpatient,,,186,,,,80,,148.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,144.52,percent of total billed charges,,,95,,176.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,176.7,
XR Shoulder Intern/Extern Rotation Left,32073030,CDM,320,RC,73030,CPT,,,Outpatient,,,255,,,,80,,204,percent of total billed charges,,,,50,70.16,fee schedule,,,77.7,,198.14,percent of total billed charges,,,95,,242.25,percent of total billed charges,,,60,,153,percent of total billed charges,,153,242.25,
XR Shoulder Intern/Extern Rotation Right,32073030,CDM,320,RC,73030,CPT,,,Outpatient,,,255,,,,80,,204,percent of total billed charges,,,,50,70.16,fee schedule,,,77.7,,198.14,percent of total billed charges,,,95,,242.25,percent of total billed charges,,,60,,153,percent of total billed charges,,153,242.25,
XR Shoulder Intern/Extern Rotation Left,32073030,CDM,320,RC,73030,CPT,,,Inpatient,,,255,,,,80,,204,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,198.14,percent of total billed charges,,,95,,242.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,242.25,
XR Shoulder Intern/Extern Rotation Right,32073030,CDM,320,RC,73030,CPT,,,Inpatient,,,255,,,,80,,204,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,198.14,percent of total billed charges,,,95,,242.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,242.25,
XR AC Joints Bilateral w/ + w/o wts,32073050,CDM,320,RC,73050,CPT,,,Outpatient,,,216,,,,80,,172.8,percent of total billed charges,,,,50,73.41,fee schedule,,,77.7,,167.83,percent of total billed charges,,,95,,205.2,percent of total billed charges,,,60,,129.6,percent of total billed charges,,129.6,205.2,
XR AC Joints Bilateral w/ + w/o wts,32073050,CDM,320,RC,73050,CPT,,,Inpatient,,,216,,,,80,,172.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,167.83,percent of total billed charges,,,95,,205.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,205.2,
XR Wrist Complete w/ Navicular Left,32073110,CDM,320,RC,73110,CPT,,,Outpatient,,,230,,,,80,,184,percent of total billed charges,,,,50,71.55,fee schedule,,,77.7,,178.71,percent of total billed charges,,,95,,218.5,percent of total billed charges,,,60,,138,percent of total billed charges,,138,218.5,
XR Wrist Complete w/ Navicular Right,32073110,CDM,320,RC,73110,CPT,,,Outpatient,,,230,,,,80,,184,percent of total billed charges,,,,50,71.55,fee schedule,,,77.7,,178.71,percent of total billed charges,,,95,,218.5,percent of total billed charges,,,60,,138,percent of total billed charges,,138,218.5,
XR Wrist Complete w/ Navicular Left,32073110,CDM,320,RC,73110,CPT,,,Inpatient,,,230,,,,80,,184,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,178.71,percent of total billed charges,,,95,,218.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,218.5,
XR Wrist Complete w/ Navicular Right,32073110,CDM,320,RC,73110,CPT,,,Inpatient,,,230,,,,80,,184,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,178.71,percent of total billed charges,,,95,,218.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,218.5,
XR Fingers Left,32073140,CDM,320,RC,73140,CPT,,,Outpatient,,,140,,,,80,,112,percent of total billed charges,,,,50,52.97,fee schedule,,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,60,,84,percent of total billed charges,,84,133,
XR Fingers Rt,32073140,CDM,320,RC,73140,CPT,,,Outpatient,,,140,,,,80,,112,percent of total billed charges,,,,50,52.97,fee schedule,,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,60,,84,percent of total billed charges,,84,133,
XR Fingers Left,32073140,CDM,320,RC,73140,CPT,,,Inpatient,,,140,,,,80,,112,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,133,
XR Fingers Rt,32073140,CDM,320,RC,73140,CPT,,,Inpatient,,,140,,,,80,,112,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,133,
XR Hip 2-3 Views Lt w/ Pelvis,32073502,CDM,320,RC,73502,CPT,,,Outpatient,,,193,,,,80,,154.4,percent of total billed charges,,,,50,86.63,fee schedule,,,77.7,,149.96,percent of total billed charges,,,95,,183.35,percent of total billed charges,,,60,,115.8,percent of total billed charges,,115.8,183.35,
XR Hip 2-3 Views Rt w/ Pelvis,32073502,CDM,320,RC,73502,CPT,,,Outpatient,,,193,,,,80,,154.4,percent of total billed charges,,,,50,86.63,fee schedule,,,77.7,,149.96,percent of total billed charges,,,95,,183.35,percent of total billed charges,,,60,,115.8,percent of total billed charges,,115.8,183.35,
XR Hip 2-3 Views Lt w/ Pelvis,32073502,CDM,320,RC,73502,CPT,,,Inpatient,,,193,,,,80,,154.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,149.96,percent of total billed charges,,,95,,183.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,183.35,
XR Hip 2-3 Views Rt w/ Pelvis,32073502,CDM,320,RC,73502,CPT,,,Inpatient,,,193,,,,80,,154.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,149.96,percent of total billed charges,,,95,,183.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,183.35,
XR Femur 1 View Rt,32073551,CDM,320,RC,73551,CPT,,,Outpatient,,,241,,,,80,,192.8,percent of total billed charges,,,,85,204.85,percent of total billed charges,,,77.7,,187.26,percent of total billed charges,,,95,,228.95,percent of total billed charges,,,60,,144.6,percent of total billed charges,,144.6,228.95,
XR Femur 1 View Rt,32073551,CDM,320,RC,73551,CPT,,,Inpatient,,,241,,,,80,,192.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,187.26,percent of total billed charges,,,95,,228.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,228.95,
XR Knee Standing + Knee - Right,32073565,CDM,320,RC,73565,CPT,,,Outpatient,,,161,,,,80,,128.8,percent of total billed charges,,,,50,54.83,fee schedule,,,77.7,,125.1,percent of total billed charges,,,95,,152.95,percent of total billed charges,,,60,,96.6,percent of total billed charges,,96.6,152.95,
XR Knee Standing + Knee - Right,32073565,CDM,320,RC,73565,CPT,,,Inpatient,,,161,,,,80,,128.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,125.1,percent of total billed charges,,,95,,152.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,152.95,
XR Calcaneus Left,32073650,CDM,320,RC,73650,CPT,,,Outpatient,,,150,,,,80,,120,percent of total billed charges,,,,50,57.15,fee schedule,,,77.7,,116.55,percent of total billed charges,,,95,,142.5,percent of total billed charges,,,60,,90,percent of total billed charges,,90,142.5,
XR Calcaneus Right,32073650,CDM,320,RC,73650,CPT,,,Outpatient,,,150,,,,80,,120,percent of total billed charges,,,,50,57.15,fee schedule,,,77.7,,116.55,percent of total billed charges,,,95,,142.5,percent of total billed charges,,,60,,90,percent of total billed charges,,90,142.5,
XR Calcaneus Left,32073650,CDM,320,RC,73650,CPT,,,Inpatient,,,150,,,,80,,120,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,116.55,percent of total billed charges,,,95,,142.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,142.5,
XR Calcaneus Right,32073650,CDM,320,RC,73650,CPT,,,Inpatient,,,150,,,,80,,120,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,116.55,percent of total billed charges,,,95,,142.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,142.5,
XR Toes Left,32073660,CDM,320,RC,73660,CPT,,,Outpatient,,,140,,,,80,,112,percent of total billed charges,,,,50,53.9,fee schedule,,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,60,,84,percent of total billed charges,,84,133,
XR Toes Rt,32073660,CDM,320,RC,73660,CPT,,,Outpatient,,,140,,,,80,,112,percent of total billed charges,,,,50,53.9,fee schedule,,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,60,,84,percent of total billed charges,,84,133,
XR Toes Left,32073660,CDM,320,RC,73660,CPT,,,Inpatient,,,140,,,,80,,112,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,133,
XR Toes Rt,32073660,CDM,320,RC,73660,CPT,,,Inpatient,,,140,,,,80,,112,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,108.78,percent of total billed charges,,,95,,133,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,133,
XR Abdomen Flat/Upright,32074019,CDM,320,RC,74019,CPT,,,Outpatient,,,313,,,,80,,250.4,percent of total billed charges,,,,50,50.18,fee schedule,,,77.7,,243.2,percent of total billed charges,,,95,,297.35,percent of total billed charges,,,60,,187.8,percent of total billed charges,,187.8,297.35,
XR Abdomen Flat/Upright,32074019,CDM,320,RC,74019,CPT,,,Inpatient,,,313,,,,80,,250.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,243.2,percent of total billed charges,,,95,,297.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,297.35,
XR Bone Survey Infant,32077076,CDM,320,RC,77076,CPT,,,Outpatient,,,200,,,,80,,160,percent of total billed charges,,,,85,170,percent of total billed charges,,,77.7,,155.4,percent of total billed charges,,,95,,190,percent of total billed charges,,,60,,120,percent of total billed charges,,120,190,
XR Bone Survey Infant,32077076,CDM,320,RC,77076,CPT,,,Inpatient,,,200,,,,80,,160,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,155.4,percent of total billed charges,,,95,,190,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,190,
NM Thyroid Imaging w/ Uptake Multiple,34178012,CDM,341,RC,78012,CPT,,,Outpatient,,,694,,,,80,,555.2,percent of total billed charges,,,,50,101.75,fee schedule,,,77.7,,539.24,percent of total billed charges,,,95,,659.3,percent of total billed charges,,,60,,416.4,percent of total billed charges,,416.4,659.3,
NM Thyroid Imaging w/ Uptake Single,34178012,CDM,341,RC,78012,CPT,,,Outpatient,,,694,,,,80,,555.2,percent of total billed charges,,,,50,101.75,fee schedule,,,77.7,,539.24,percent of total billed charges,,,95,,659.3,percent of total billed charges,,,60,,416.4,percent of total billed charges,,416.4,659.3,
NM Thyroid Imaging w/ Uptake Multiple,34178012,CDM,341,RC,78012,CPT,,,Inpatient,,,694,,,,80,,555.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,539.24,percent of total billed charges,,,95,,659.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,659.3,
NM Thyroid Imaging w/ Uptake Single,34178012,CDM,341,RC,78012,CPT,,,Inpatient,,,694,,,,80,,555.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,539.24,percent of total billed charges,,,95,,659.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,659.3,
NM Thyroid Imaging Only,34178013,CDM,341,RC,78013,CPT,,,Outpatient,,,398,,,,80,,318.4,percent of total billed charges,,,,50,167.26,fee schedule,,,77.7,,309.25,percent of total billed charges,,,95,,378.1,percent of total billed charges,,,60,,238.8,percent of total billed charges,,238.8,378.1,
NM Thyroid Imaging with Vascular Flow,34178013,CDM,341,RC,78013,CPT,,,Outpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,50,167.26,fee schedule,,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,60,,250.8,percent of total billed charges,,250.8,397.1,
NM Thyroid Imaging Only,34178013,CDM,341,RC,78013,CPT,,,Inpatient,,,398,,,,80,,318.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,309.25,percent of total billed charges,,,95,,378.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,378.1,
NM Thyroid Imaging with Vascular Flow,34178013,CDM,341,RC,78013,CPT,,,Inpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,397.1,
NM Parathyroid Study,34178070,CDM,341,RC,78070,CPT,,,Outpatient,,,385,,,,80,,308,percent of total billed charges,,,,85,327.25,percent of total billed charges,,,77.7,,299.15,percent of total billed charges,,,95,,365.75,percent of total billed charges,,,60,,231,percent of total billed charges,,231,365.75,
NM Parathyroid Study,34178070,CDM,341,RC,78070,CPT,,,Inpatient,,,385,,,,80,,308,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,299.15,percent of total billed charges,,,95,,365.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,365.75,
NM Salivary Gland Imaging,34178099,CDM,341,RC,78099,CPT,,,Outpatient,,,448,,,,80,,358.4,percent of total billed charges,,,,85,380.8,percent of total billed charges,,,77.7,,348.1,percent of total billed charges,,,95,,425.6,percent of total billed charges,,,60,,268.8,percent of total billed charges,,268.8,425.6,
NM Salivary Gland Imaging,34178099,CDM,341,RC,78099,CPT,,,Inpatient,,,448,,,,80,,358.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,348.1,percent of total billed charges,,,95,,425.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,425.6,
NM Liver/Spleen Imaging w/ Vascular Flow,34178216,CDM,341,RC,78216,CPT,,,Outpatient,,,921,,,,80,,736.8,percent of total billed charges,,,,85,782.85,percent of total billed charges,,,77.7,,715.62,percent of total billed charges,,,95,,874.95,percent of total billed charges,,,60,,552.6,percent of total billed charges,,552.6,874.95,
NM Liver/Spleen Imaging w/ Vascular Flow,34178216,CDM,341,RC,78216,CPT,,,Inpatient,,,921,,,,80,,736.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,715.62,percent of total billed charges,,,95,,874.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,874.95,
NM Hepatobiliary Duct System Imaging,34178226,CDM,341,RC,78226,CPT,,,Outpatient,,,921,,,,80,,736.8,percent of total billed charges,,,,50,264.82,fee schedule,,,77.7,,715.62,percent of total billed charges,,,95,,874.95,percent of total billed charges,,,60,,552.6,percent of total billed charges,,552.6,874.95,
NM Hepatobiliary Duct System Imaging,34178226,CDM,341,RC,78226,CPT,,,Inpatient,,,921,,,,80,,736.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,715.62,percent of total billed charges,,,95,,874.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,874.95,
NM Gastric Emptying Study,34178264,CDM,341,RC,78264,CPT,,,Outpatient,,,1050,,,,80,,840,percent of total billed charges,,,,50,134.74,fee schedule,,,77.7,,815.85,percent of total billed charges,,,95,,997.5,percent of total billed charges,,,60,,630,percent of total billed charges,,630,997.5,
NM Gastric Emptying Study,34178264,CDM,341,RC,78264,CPT,,,Inpatient,,,1050,,,,80,,840,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,815.85,percent of total billed charges,,,95,,997.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,997.5,
NM Gastrointestinal Blood Loss Imaging,34178278,CDM,341,RC,78278,CPT,,,Outpatient,,,781,,,,80,,624.8,percent of total billed charges,,,,85,663.85,percent of total billed charges,,,77.7,,606.84,percent of total billed charges,,,95,,741.95,percent of total billed charges,,,60,,468.6,percent of total billed charges,,468.6,741.95,
NM Gastrointestinal Blood Loss Imaging,34178278,CDM,341,RC,78278,CPT,,,Inpatient,,,781,,,,80,,624.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,606.84,percent of total billed charges,,,95,,741.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,741.95,
NM Bone Imaging Limited,34178300,CDM,341,RC,78300,CPT,,,Outpatient,,,794,,,,80,,635.2,percent of total billed charges,,,,50,171.9,fee schedule,,,77.7,,616.94,percent of total billed charges,,,95,,754.3,percent of total billed charges,,,60,,476.4,percent of total billed charges,,476.4,754.3,
NM Bone Imaging Limited,34178300,CDM,341,RC,78300,CPT,,,Inpatient,,,794,,,,80,,635.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,616.94,percent of total billed charges,,,95,,754.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,754.3,
NM Bone Imaging Limited Multiple Areas,34178305,CDM,341,RC,78305,CPT,,,Outpatient,,,794,,,,80,,635.2,percent of total billed charges,,,,85,674.9,percent of total billed charges,,,77.7,,616.94,percent of total billed charges,,,95,,754.3,percent of total billed charges,,,60,,476.4,percent of total billed charges,,476.4,754.3,
NM Bone Imaging Limited Multiple Areas,34178305,CDM,341,RC,78305,CPT,,,Inpatient,,,794,,,,80,,635.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,616.94,percent of total billed charges,,,95,,754.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,754.3,
NM Bone Imaging Whole Body,34178306,CDM,341,RC,78306,CPT,,,Outpatient,,,794,,,,80,,635.2,percent of total billed charges,,,,50,200.25,fee schedule,,,77.7,,616.94,percent of total billed charges,,,95,,754.3,percent of total billed charges,,,60,,476.4,percent of total billed charges,,476.4,754.3,
NM Bone Imaging Whole Body,34178306,CDM,341,RC,78306,CPT,,,Inpatient,,,794,,,,80,,635.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,616.94,percent of total billed charges,,,95,,754.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,754.3,
NM Bone Three Phase Study,34178315,CDM,341,RC,78315,CPT,,,Outpatient,,,794,,,,80,,635.2,percent of total billed charges,,,,50,173.76,fee schedule,,,77.7,,616.94,percent of total billed charges,,,95,,754.3,percent of total billed charges,,,60,,476.4,percent of total billed charges,,476.4,754.3,
NM Bone Three Phase Study,34178315,CDM,341,RC,78315,CPT,,,Inpatient,,,794,,,,80,,635.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,616.94,percent of total billed charges,,,95,,754.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,754.3,
NM multispec 78452,34178452,CDM,341,RC,78452,CPT,,,Outpatient,,,2446,,,,80,,1956.8,percent of total billed charges,,,,50,734.04,fee schedule,,,77.7,,1900.54,percent of total billed charges,,,95,,2323.7,percent of total billed charges,,,60,,1467.6,percent of total billed charges,,1467.6,2323.7,
NM Myocardial Spect Multi Rest/Stress,34178452,CDM,341,RC,78452,CPT,,,Outpatient,,,2446,,,,80,,1956.8,percent of total billed charges,,,,50,734.04,fee schedule,,,77.7,,1900.54,percent of total billed charges,,,95,,2323.7,percent of total billed charges,,,60,,1467.6,percent of total billed charges,,1467.6,2323.7,
NM multispec 78452,34178452,CDM,341,RC,78452,CPT,,,Inpatient,,,2446,,,,80,,1956.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1900.54,percent of total billed charges,,,95,,2323.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2323.7,
NM Myocardial Spect Multi Rest/Stress,34178452,CDM,341,RC,78452,CPT,,,Inpatient,,,2446,,,,80,,1956.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1900.54,percent of total billed charges,,,95,,2323.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2323.7,
NM Venous Thrombosis Imaging Left,34178457,CDM,341,RC,78457,CPT,,,Outpatient,,,1272,,,,80,,1017.6,percent of total billed charges,,,,85,1081.2,percent of total billed charges,,,77.7,,988.34,percent of total billed charges,,,95,,1208.4,percent of total billed charges,,,60,,763.2,percent of total billed charges,,763.2,1208.4,
NM Venous Thrombosis Imaging Right,34178457,CDM,341,RC,78457,CPT,,,Outpatient,,,1272,,,,80,,1017.6,percent of total billed charges,,,,85,1081.2,percent of total billed charges,,,77.7,,988.34,percent of total billed charges,,,95,,1208.4,percent of total billed charges,,,60,,763.2,percent of total billed charges,,763.2,1208.4,
NM Venous Thrombosis Imaging Left,34178457,CDM,341,RC,78457,CPT,,,Inpatient,,,1272,,,,80,,1017.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,988.34,percent of total billed charges,,,95,,1208.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1208.4,
NM Venous Thrombosis Imaging Right,34178457,CDM,341,RC,78457,CPT,,,Inpatient,,,1272,,,,80,,1017.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,988.34,percent of total billed charges,,,95,,1208.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1208.4,
NM Venous Thrombosis Imaging Bilateral,34178458,CDM,341,RC,78458,CPT,,,Outpatient,,,602,,,,80,,481.6,percent of total billed charges,,,,85,511.7,percent of total billed charges,,,77.7,,467.75,percent of total billed charges,,,95,,571.9,percent of total billed charges,,,60,,361.2,percent of total billed charges,,361.2,571.9,
NM Venous Thrombosis Imaging Bilateral,34178458,CDM,341,RC,78458,CPT,,,Inpatient,,,602,,,,80,,481.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,467.75,percent of total billed charges,,,95,,571.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,571.9,
NM Cardiac Blood Pool Single,34178472,CDM,341,RC,78472,CPT,,,Outpatient,,,1005,,,,80,,804,percent of total billed charges,,,,50,253.67,fee schedule,,,77.7,,780.89,percent of total billed charges,,,95,,954.75,percent of total billed charges,,,60,,603,percent of total billed charges,,603,954.75,
NM Cardiac Blood Pool Single,34178472,CDM,341,RC,78472,CPT,,,Inpatient,,,1005,,,,80,,804,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,780.89,percent of total billed charges,,,95,,954.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,954.75,
NM Pulmonary Perfusion Imaging,34178580,CDM,341,RC,78580,CPT,,,Outpatient,,,670,,,,80,,536,percent of total billed charges,,,,85,569.5,percent of total billed charges,,,77.7,,520.59,percent of total billed charges,,,95,,636.5,percent of total billed charges,,,60,,402,percent of total billed charges,,402,636.5,
NM Pulmonary Perfusion Imaging,34178580,CDM,341,RC,78580,CPT,,,Inpatient,,,670,,,,80,,536,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,520.59,percent of total billed charges,,,95,,636.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,636.5,
NM Pulmonary Perfusion w/ Ventilation,34178582,CDM,341,RC,78582,CPT,,,Outpatient,,,1116,,,,80,,892.8,percent of total billed charges,,,,50,346.59,fee schedule,,,77.7,,867.13,percent of total billed charges,,,95,,1060.2,percent of total billed charges,,,60,,669.6,percent of total billed charges,,669.6,1060.2,
NM Pulmonary Perfusion w/ Ventilation,34178582,CDM,341,RC,78582,CPT,,,Inpatient,,,1116,,,,80,,892.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,867.13,percent of total billed charges,,,95,,1060.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1060.2,
NM Kidney Imaging Static,34178700,CDM,341,RC,78700,CPT,,,Outpatient,,,1017,,,,80,,813.6,percent of total billed charges,,,,85,864.45,percent of total billed charges,,,77.7,,790.21,percent of total billed charges,,,95,,966.15,percent of total billed charges,,,60,,610.2,percent of total billed charges,,610.2,966.15,
NM Kidney Imaging Static,34178700,CDM,341,RC,78700,CPT,,,Inpatient,,,1017,,,,80,,813.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,790.21,percent of total billed charges,,,95,,966.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,966.15,
NM Kidney Imaging w/ Vascular Flow,34178701,CDM,341,RC,78701,CPT,,,Outpatient,,,1017,,,,80,,813.6,percent of total billed charges,,,,85,864.45,percent of total billed charges,,,77.7,,790.21,percent of total billed charges,,,95,,966.15,percent of total billed charges,,,60,,610.2,percent of total billed charges,,610.2,966.15,
NM Kidney Imaging w/ Vascular Flow,34178701,CDM,341,RC,78701,CPT,,,Inpatient,,,1017,,,,80,,813.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,790.21,percent of total billed charges,,,95,,966.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,966.15,
NM Kidney Imaging w/ Flow w/o Pharm,34178707,CDM,341,RC,78707,CPT,,,Outpatient,,,1017,,,,80,,813.6,percent of total billed charges,,,,85,864.45,percent of total billed charges,,,77.7,,790.21,percent of total billed charges,,,95,,966.15,percent of total billed charges,,,60,,610.2,percent of total billed charges,,610.2,966.15,
NM Kidney Imaging w/ Flow w/o Pharm,34178707,CDM,341,RC,78707,CPT,,,Inpatient,,,1017,,,,80,,813.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,790.21,percent of total billed charges,,,95,,966.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,966.15,
NM Kidney Imaging w/ Flow w/ Pharm,34178708,CDM,341,RC,78708,CPT,,,Outpatient,,,1017,,,,80,,813.6,percent of total billed charges,,,,50,420,fee schedule,,,77.7,,790.21,percent of total billed charges,,,95,,966.15,percent of total billed charges,,,60,,610.2,percent of total billed charges,,610.2,966.15,
NM Kidney Imaging w/ Flow w/ Pharm,34178708,CDM,341,RC,78708,CPT,,,Inpatient,,,1017,,,,80,,813.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,790.21,percent of total billed charges,,,95,,966.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,966.15,
NM Ureteral Reflux Study,34178740,CDM,341,RC,78740,CPT,,,Outpatient,,,1017,,,,80,,813.6,percent of total billed charges,,,,85,864.45,percent of total billed charges,,,77.7,,790.21,percent of total billed charges,,,95,,966.15,percent of total billed charges,,,60,,610.2,percent of total billed charges,,610.2,966.15,
NM Ureteral Reflux Study,34178740,CDM,341,RC,78740,CPT,,,Inpatient,,,1017,,,,80,,813.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,790.21,percent of total billed charges,,,95,,966.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,966.15,
NM Testicular Imaging,34178761,CDM,341,RC,78761,CPT,,,Outpatient,,,1017,,,,80,,813.6,percent of total billed charges,,,,85,864.45,percent of total billed charges,,,77.7,,790.21,percent of total billed charges,,,95,,966.15,percent of total billed charges,,,60,,610.2,percent of total billed charges,,610.2,966.15,
NM Testicular Imaging w/ Vascular Flow,34178761,CDM,341,RC,78761,CPT,,,Outpatient,,,1017,,,,80,,813.6,percent of total billed charges,,,,85,864.45,percent of total billed charges,,,77.7,,790.21,percent of total billed charges,,,95,,966.15,percent of total billed charges,,,60,,610.2,percent of total billed charges,,610.2,966.15,
NM Testicular Imaging,34178761,CDM,341,RC,78761,CPT,,,Inpatient,,,1017,,,,80,,813.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,790.21,percent of total billed charges,,,95,,966.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,966.15,
NM Testicular Imaging w/ Vascular Flow,34178761,CDM,341,RC,78761,CPT,,,Inpatient,,,1017,,,,80,,813.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,790.21,percent of total billed charges,,,95,,966.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,966.15,
NM Tumor Localization/Limited,34178800,CDM,341,RC,78800,CPT,,,Outpatient,,,950,,,,80,,760,percent of total billed charges,,,,85,807.5,percent of total billed charges,,,77.7,,738.15,percent of total billed charges,,,95,,902.5,percent of total billed charges,,,60,,570,percent of total billed charges,,570,902.5,
NM Tumor Localization/Limited,34178800,CDM,341,RC,78800,CPT,,,Inpatient,,,950,,,,80,,760,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,738.15,percent of total billed charges,,,95,,902.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,902.5,
NM Tumor Localization/Multiple Areas,34178801,CDM,341,RC,78801,CPT,,,Outpatient,,,1591,,,,80,,1272.8,percent of total billed charges,,,,85,1352.35,percent of total billed charges,,,77.7,,1236.21,percent of total billed charges,,,95,,1511.45,percent of total billed charges,,,60,,954.6,percent of total billed charges,,954.6,1511.45,
NM Tumor Localization/Multiple Areas,34178801,CDM,341,RC,78801,CPT,,,Inpatient,,,1591,,,,80,,1272.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1236.21,percent of total billed charges,,,95,,1511.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1511.45,
CT Orbit Sella etc. w/o Contrast,35070480,CDM,350,RC,70480,CPT,,,Outpatient,,,1158,,,,80,,926.4,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,899.77,percent of total billed charges,,,95,,1100.1,percent of total billed charges,,,60,,694.8,percent of total billed charges,,694.8,1100.1,
CT Orbit Sella etc. w/o Contrast,35070480,CDM,350,RC,70480,CPT,,,Inpatient,,,1158,,,,80,,926.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,899.77,percent of total billed charges,,,95,,1100.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1100.1,
CT Maxillofacial w/ Contrast,35070487,CDM,350,RC,70487,CPT,,,Outpatient,,,570.31,,,,80,,456.25,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,443.13,percent of total billed charges,,,95,,541.79,percent of total billed charges,,,60,,342.19,percent of total billed charges,,342.19,541.79,
CT Maxillofacial w/ Contrast,35070487,CDM,350,RC,70487,CPT,,,Inpatient,,,570.31,,,,80,,456.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,443.13,percent of total billed charges,,,95,,541.79,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,541.79,
CT Head + Maxilllofacial w/o Contrast,35070488,CDM,350,RC,70488,CPT,,,Outpatient,,,1409,,,,80,,1127.2,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,1094.79,percent of total billed charges,,,95,,1338.55,percent of total billed charges,,,60,,845.4,percent of total billed charges,,845.4,1338.55,
CT Head + Maxilllofacial w/o Contrast,35070488,CDM,350,RC,70488,CPT,,,Inpatient,,,1409,,,,80,,1127.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1094.79,percent of total billed charges,,,95,,1338.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1338.55,
CT Soft Tissue Neck w/ + w/o Contrast,35070492,CDM,350,RC,70492,CPT,,,Outpatient,,,1208,,,,80,,966.4,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,938.62,percent of total billed charges,,,95,,1147.6,percent of total billed charges,,,60,,724.8,percent of total billed charges,,724.8,1147.6,
CT Soft Tissue Neck w/ + w/o Contrast,35070492,CDM,350,RC,70492,CPT,,,Inpatient,,,1208,,,,80,,966.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,938.62,percent of total billed charges,,,95,,1147.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1147.6,
CT Angiography Head + Neck,35070496,CDM,350,RC,70496,CPT,,,Outpatient,,,2625,,,,80,,2100,percent of total billed charges,,,,50,579.36,fee schedule,,,77.7,,2039.63,percent of total billed charges,,,95,,2493.75,percent of total billed charges,,,60,,1575,percent of total billed charges,,1575,2493.75,
CT Angiography Head + Neck,35070496,CDM,350,RC,70496,CPT,,,Inpatient,,,2625,,,,80,,2100,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2039.63,percent of total billed charges,,,95,,2493.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2493.75,
70498 CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRAST,35070498,CDM,350,RC,70498,CPT,,,Outpatient,,,2825,,,,80,,2260,percent of total billed charges,,,,50,579.82,fee schedule,,,77.7,,2195.03,percent of total billed charges,,,95,,2683.75,percent of total billed charges,,,60,,1695,percent of total billed charges,,1695,2683.75,
70498 CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRAST,35070498,CDM,350,RC,70498,CPT,,,Inpatient,,,2825,,,,80,,2260,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2195.03,percent of total billed charges,,,95,,2683.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2683.75,
71250 CT DIAGNOSTIC THORAX W/O CNTRST,35071250,CDM,350,RC,71250,CPT,,,Outpatient,,,900,,,,80,,720,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,699.3,percent of total billed charges,,,95,,855,percent of total billed charges,,,60,,540,percent of total billed charges,,540,855,
71250 CT DIAGNOSTIC THORAX W/O CNTRST,35071250,CDM,350,RC,71250,CPT,,,Inpatient,,,900,,,,80,,720,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,699.3,percent of total billed charges,,,95,,855,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,855,
71260 CT DIAGNOSTIC  THORAX W/CONTRAST,35071260,CDM,350,RC,71260,CPT,,,Outpatient,,,900,,,,80,,720,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,699.3,percent of total billed charges,,,95,,855,percent of total billed charges,,,60,,540,percent of total billed charges,,540,855,
71260 CT DIAGNOSTIC  THORAX W/CONTRAST,35071260,CDM,350,RC,71260,CPT,,,Inpatient,,,900,,,,80,,720,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,699.3,percent of total billed charges,,,95,,855,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,855,
71270 CT DIAGNOSTIC COMPUTED TOMOGRAPHY THORAX C-/C+,35071270,CDM,350,RC,71270,CPT,,,Outpatient,,,900,,,,80,,720,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,699.3,percent of total billed charges,,,95,,855,percent of total billed charges,,,60,,540,percent of total billed charges,,540,855,
71270 CT DIAGNOSTIC COMPUTED TOMOGRAPHY THORAX C-/C+,35071270,CDM,350,RC,71270,CPT,,,Inpatient,,,900,,,,80,,720,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,699.3,percent of total billed charges,,,95,,855,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,855,
CT Angiography Chest w,35071275,CDM,350,RC,71275,CPT,,,Outpatient,,,2795,,,,80,,2236,percent of total billed charges,,,,50,571.93,fee schedule,,,77.7,,2171.72,percent of total billed charges,,,95,,2655.25,percent of total billed charges,,,60,,1677,percent of total billed charges,,1677,2655.25,
CT Angiography Chest w/ + w/o Contrast,35071275,CDM,350,RC,71275,CPT,,,Outpatient,,,2795,,,,80,,2236,percent of total billed charges,,,,50,571.93,fee schedule,,,77.7,,2171.72,percent of total billed charges,,,95,,2655.25,percent of total billed charges,,,60,,1677,percent of total billed charges,,1677,2655.25,
CT Angiography Chest w,35071275,CDM,350,RC,71275,CPT,,,Inpatient,,,2795,,,,80,,2236,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2171.72,percent of total billed charges,,,95,,2655.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2655.25,
CT Angiography Chest w/ + w/o Contrast,35071275,CDM,350,RC,71275,CPT,,,Inpatient,,,2795,,,,80,,2236,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2171.72,percent of total billed charges,,,95,,2655.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2655.25,
CT Spine Cervical w/ Contrast,35072126,CDM,350,RC,72126,CPT,,,Outpatient,,,2092,,,,80,,1673.6,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,1625.48,percent of total billed charges,,,95,,1987.4,percent of total billed charges,,,60,,1255.2,percent of total billed charges,,1255.2,1987.4,
CT Spine Cervical w/ Contrast,35072126,CDM,350,RC,72126,CPT,,,Inpatient,,,2092,,,,80,,1673.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1625.48,percent of total billed charges,,,95,,1987.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1987.4,
CT Spine Cervical w/ + w/o Contrast,35072127,CDM,350,RC,72127,CPT,,,Outpatient,,,1174,,,,80,,939.2,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,912.2,percent of total billed charges,,,95,,1115.3,percent of total billed charges,,,60,,704.4,percent of total billed charges,,704.4,1115.3,
CT Spine Cervical w/ + w/o Contrast,35072127,CDM,350,RC,72127,CPT,,,Inpatient,,,1174,,,,80,,939.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,912.2,percent of total billed charges,,,95,,1115.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1115.3,
CT Spine Thoracic w/ + w/o Contrast,35072130,CDM,350,RC,72130,CPT,,,Outpatient,,,1174,,,,80,,939.2,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,912.2,percent of total billed charges,,,95,,1115.3,percent of total billed charges,,,60,,704.4,percent of total billed charges,,704.4,1115.3,
CT Spine Thoracic w/ + w/o Contrast,35072130,CDM,350,RC,72130,CPT,,,Inpatient,,,1174,,,,80,,939.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,912.2,percent of total billed charges,,,95,,1115.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1115.3,
CT Spine Lumbar w/ + w/o Contrast,35072133,CDM,350,RC,72133,CPT,,,Outpatient,,,1174,,,,80,,939.2,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,912.2,percent of total billed charges,,,95,,1115.3,percent of total billed charges,,,60,,704.4,percent of total billed charges,,704.4,1115.3,
CT Spine Lumbar w/ + w/o Contrast,35072133,CDM,350,RC,72133,CPT,,,Inpatient,,,1174,,,,80,,939.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,912.2,percent of total billed charges,,,95,,1115.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1115.3,
CT Angiography Pelvis w/ + w/o Contrast,35072191,CDM,350,RC,72191,CPT,,,Outpatient,,,2625,,,,80,,2100,percent of total billed charges,,,,85,2231.25,percent of total billed charges,,,77.7,,2039.63,percent of total billed charges,,,95,,2493.75,percent of total billed charges,,,60,,1575,percent of total billed charges,,1575,2493.75,
CT Angiography Pelvis w/ + w/o Contrast,35072191,CDM,350,RC,72191,CPT,,,Inpatient,,,2625,,,,80,,2100,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2039.63,percent of total billed charges,,,95,,2493.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2493.75,
CT Pelvis w/ + w/o Contrast,35072194,CDM,350,RC,72194,CPT,,,Outpatient,,,1351,,,,80,,1080.8,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,1049.73,percent of total billed charges,,,95,,1283.45,percent of total billed charges,,,60,,810.6,percent of total billed charges,,810.6,1283.45,
CT Pelvis w/ + w/o Contrast,35072194,CDM,350,RC,72194,CPT,,,Inpatient,,,1351,,,,80,,1080.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1049.73,percent of total billed charges,,,95,,1283.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1283.45,
CT Upper Extremity w/o Contrast Left,35073200,CDM,350,RC,73200,CPT,,,Outpatient,,,1172,,,,80,,937.6,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,910.64,percent of total billed charges,,,95,,1113.4,percent of total billed charges,,,60,,703.2,percent of total billed charges,,703.2,1113.4,
CT Upper Extremity w/o Contrast Right,35073200,CDM,350,RC,73200,CPT,,,Outpatient,,,1172,,,,80,,937.6,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,910.64,percent of total billed charges,,,95,,1113.4,percent of total billed charges,,,60,,703.2,percent of total billed charges,,703.2,1113.4,
CT Upper Extremity w/o Contrast Left,35073200,CDM,350,RC,73200,CPT,,,Inpatient,,,1172,,,,80,,937.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,910.64,percent of total billed charges,,,95,,1113.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1113.4,
CT Upper Extremity w/o Contrast Right,35073200,CDM,350,RC,73200,CPT,,,Inpatient,,,1172,,,,80,,937.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,910.64,percent of total billed charges,,,95,,1113.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1113.4,
CT Upper Extremity w/+w/o Contrast Left,35073202,CDM,350,RC,73202,CPT,,,Outpatient,,,1351,,,,80,,1080.8,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,1049.73,percent of total billed charges,,,95,,1283.45,percent of total billed charges,,,60,,810.6,percent of total billed charges,,810.6,1283.45,
CT Upper Extremity w/+w/o Contrast Right,35073202,CDM,350,RC,73202,CPT,,,Outpatient,,,1351,,,,80,,1080.8,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,1049.73,percent of total billed charges,,,95,,1283.45,percent of total billed charges,,,60,,810.6,percent of total billed charges,,810.6,1283.45,
CT Upper Extremity w/+w/o Contrast Left,35073202,CDM,350,RC,73202,CPT,,,Inpatient,,,1351,,,,80,,1080.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1049.73,percent of total billed charges,,,95,,1283.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1283.45,
CT Upper Extremity w/+w/o Contrast Right,35073202,CDM,350,RC,73202,CPT,,,Inpatient,,,1351,,,,80,,1080.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1049.73,percent of total billed charges,,,95,,1283.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1283.45,
CT Angiography Upper Extremity Left,35073206,CDM,350,RC,73206,CPT,,,Outpatient,,,2625,,,,80,,2100,percent of total billed charges,,,,85,2231.25,percent of total billed charges,,,77.7,,2039.63,percent of total billed charges,,,95,,2493.75,percent of total billed charges,,,60,,1575,percent of total billed charges,,1575,2493.75,
CT Angiography Upper Extremity Right,35073206,CDM,350,RC,73206,CPT,,,Outpatient,,,2625,,,,80,,2100,percent of total billed charges,,,,85,2231.25,percent of total billed charges,,,77.7,,2039.63,percent of total billed charges,,,95,,2493.75,percent of total billed charges,,,60,,1575,percent of total billed charges,,1575,2493.75,
CT Angiography Upper Extremity Left,35073206,CDM,350,RC,73206,CPT,,,Inpatient,,,2625,,,,80,,2100,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2039.63,percent of total billed charges,,,95,,2493.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2493.75,
CT Angiography Upper Extremity Right,35073206,CDM,350,RC,73206,CPT,,,Inpatient,,,2625,,,,80,,2100,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2039.63,percent of total billed charges,,,95,,2493.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2493.75,
CT Lower Extremity w/o Contrast Left,35073700,CDM,350,RC,73700,CPT,,,Outpatient,,,1155,,,,80,,924,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,897.44,percent of total billed charges,,,95,,1097.25,percent of total billed charges,,,60,,693,percent of total billed charges,,693,1097.25,
CT Lower Extremity w/o Contrast Right,35073700,CDM,350,RC,73700,CPT,,,Outpatient,,,1155,,,,80,,924,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,897.44,percent of total billed charges,,,95,,1097.25,percent of total billed charges,,,60,,693,percent of total billed charges,,693,1097.25,
CT Lower Extremity w/o Contrast Left,35073700,CDM,350,RC,73700,CPT,,,Inpatient,,,1155,,,,80,,924,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,897.44,percent of total billed charges,,,95,,1097.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1097.25,
CT Lower Extremity w/o Contrast Right,35073700,CDM,350,RC,73700,CPT,,,Inpatient,,,1155,,,,80,,924,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,897.44,percent of total billed charges,,,95,,1097.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1097.25,
CT Lower Extremity w/+w/o Contrast Left,35073702,CDM,350,RC,73702,CPT,,,Outpatient,,,1351,,,,80,,1080.8,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,1049.73,percent of total billed charges,,,95,,1283.45,percent of total billed charges,,,60,,810.6,percent of total billed charges,,810.6,1283.45,
CT Lower Extremity w/+w/o Contrast Right,35073702,CDM,350,RC,73702,CPT,,,Outpatient,,,1351,,,,80,,1080.8,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,1049.73,percent of total billed charges,,,95,,1283.45,percent of total billed charges,,,60,,810.6,percent of total billed charges,,810.6,1283.45,
CT Lower Extremity w/+w/o Contrast Left,35073702,CDM,350,RC,73702,CPT,,,Inpatient,,,1351,,,,80,,1080.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1049.73,percent of total billed charges,,,95,,1283.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1283.45,
CT Lower Extremity w/+w/o Contrast Right,35073702,CDM,350,RC,73702,CPT,,,Inpatient,,,1351,,,,80,,1080.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1049.73,percent of total billed charges,,,95,,1283.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1283.45,
CT Angiography Lower Extremity Right,35073706,CDM,350,RC,73706,CPT,,,Outpatient,,,2625,,,,80,,2100,percent of total billed charges,,,,85,2231.25,percent of total billed charges,,,77.7,,2039.63,percent of total billed charges,,,95,,2493.75,percent of total billed charges,,,60,,1575,percent of total billed charges,,1575,2493.75,
CT Angiography Lower Extremity Right,35073706,CDM,350,RC,73706,CPT,,,Inpatient,,,2625,,,,80,,2100,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2039.63,percent of total billed charges,,,95,,2493.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2493.75,
CT Abdomen w/ + w/o Contrast,35074170,CDM,350,RC,74170,CPT,,,Outpatient,,,1805,,,,80,,1444,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,1402.49,percent of total billed charges,,,95,,1714.75,percent of total billed charges,,,60,,1083,percent of total billed charges,,1083,1714.75,
CT Abdomen w/ + w/o Contrast,35074170,CDM,350,RC,74170,CPT,,,Inpatient,,,1805,,,,80,,1444,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1402.49,percent of total billed charges,,,95,,1714.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1714.75,
CT Chest/Abdomen/Pelvis wo,35074176,CDM,350,RC,74176,CPT,,,Outpatient,,,1500,,,,80,,1200,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,1165.5,percent of total billed charges,,,95,,1425,percent of total billed charges,,,60,,900,percent of total billed charges,,900,1425,
CT Chest/Abdomen/Pelvis wo,35074176,CDM,350,RC,74176,CPT,,,Inpatient,,,1500,,,,80,,1200,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1165.5,percent of total billed charges,,,95,,1425,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1425,
CT Chest/Abdomen/Pelvis w,35074177,CDM,350,RC,74177,CPT,,,Outpatient,,,1500,,,,80,,1200,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,1165.5,percent of total billed charges,,,95,,1425,percent of total billed charges,,,60,,900,percent of total billed charges,,900,1425,
CT Chest/Abdomen/Pelvis w,35074177,CDM,350,RC,74177,CPT,,,Inpatient,,,1500,,,,80,,1200,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1165.5,percent of total billed charges,,,95,,1425,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1425,
"CT Abdomen + Pelvis wo Contrast, Stone P",35074178,CDM,350,RC,74178,CPT,,,Outpatient,,,2300,,,,80,,1840,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,1787.1,percent of total billed charges,,,95,,2185,percent of total billed charges,,,60,,1380,percent of total billed charges,,1380,2185,
CT Chest/Abdomen/Pelvis w + w/o,35074178,CDM,350,RC,74178,CPT,,,Outpatient,,,1500,,,,80,,1200,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,1165.5,percent of total billed charges,,,95,,1425,percent of total billed charges,,,60,,900,percent of total billed charges,,900,1425,
"CT Abdomen + Pelvis wo Contrast, Stone P",35074178,CDM,350,RC,74178,CPT,,,Inpatient,,,2300,,,,80,,1840,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1787.1,percent of total billed charges,,,95,,2185,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2185,
CT Chest/Abdomen/Pelvis w + w/o,35074178,CDM,350,RC,74178,CPT,,,Inpatient,,,1500,,,,80,,1200,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1165.5,percent of total billed charges,,,95,,1425,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1425,
OR Level 1 Initial 30 Min,36000000,CDM,360,RC,,,,,Outpatient,,,2596,,,,80,,2076.8,percent of total billed charges,,,,85,2206.6,percent of total billed charges,,,77.7,,2017.09,percent of total billed charges,,,95,,2466.2,percent of total billed charges,,,60,,1557.6,percent of total billed charges,,1557.6,2466.2,
OR Level 1 Initial 30 Min,36000000,CDM,360,RC,,,,,Inpatient,,,2596,,,,80,,2076.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2017.09,percent of total billed charges,,,95,,2466.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2466.2,
OR Level 1 Addl 15 Min,36000001,CDM,360,RC,,,,,Outpatient,,,866,,,,80,,692.8,percent of total billed charges,,,,85,736.1,percent of total billed charges,,,77.7,,672.88,percent of total billed charges,,,95,,822.7,percent of total billed charges,,,60,,519.6,percent of total billed charges,,519.6,822.7,
OR Level 1 Addl 15 Min,36000001,CDM,360,RC,,,,,Inpatient,,,866,,,,80,,692.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,672.88,percent of total billed charges,,,95,,822.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,822.7,
OR Level 2 Initial 30 Min,36000002,CDM,360,RC,,,,,Outpatient,,,4435,,,,80,,3548,percent of total billed charges,,,,85,3769.75,percent of total billed charges,,,77.7,,3446,percent of total billed charges,,,95,,4213.25,percent of total billed charges,,,60,,2661,percent of total billed charges,,2661,4213.25,
OR Level 2 Initial 30 Min,36000002,CDM,360,RC,,,,,Inpatient,,,4435,,,,80,,3548,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3446,percent of total billed charges,,,95,,4213.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4213.25,
OR Level 2 Addl 15 Min,36000003,CDM,360,RC,,,,,Outpatient,,,1515,,,,80,,1212,percent of total billed charges,,,,85,1287.75,percent of total billed charges,,,77.7,,1177.16,percent of total billed charges,,,95,,1439.25,percent of total billed charges,,,60,,909,percent of total billed charges,,909,1439.25,
OR Level 2 Addl 15 Min,36000003,CDM,360,RC,,,,,Inpatient,,,1515,,,,80,,1212,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1177.16,percent of total billed charges,,,95,,1439.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1439.25,
OR Level 3 Initial 30 Min,36000004,CDM,360,RC,,,,,Outpatient,,,6922,,,,80,,5537.6,percent of total billed charges,,,,85,5883.7,percent of total billed charges,,,77.7,,5378.39,percent of total billed charges,,,95,,6575.9,percent of total billed charges,,,60,,4153.2,percent of total billed charges,,4153.2,6575.9,
OR Level 3 Initial 30 Min,36000004,CDM,360,RC,,,,,Inpatient,,,6922,,,,80,,5537.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5378.39,percent of total billed charges,,,95,,6575.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6575.9,
OR Level 3 Addl 15 Min,36000005,CDM,360,RC,,,,,Outpatient,,,2380,,,,80,,1904,percent of total billed charges,,,,85,2023,percent of total billed charges,,,77.7,,1849.26,percent of total billed charges,,,95,,2261,percent of total billed charges,,,60,,1428,percent of total billed charges,,1428,2261,
OR Level 3 Addl 15 Min,36000005,CDM,360,RC,,,,,Inpatient,,,2380,,,,80,,1904,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1849.26,percent of total billed charges,,,95,,2261,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2261,
OR 10030 IMAGE-GUIDED CATHETER FLUID COLLECTION DRAINAGE,36010030,CDM,360,RC,10030,CPT,,,Outpatient,,,800,,,,80,,640,percent of total billed charges,,,,85,680,percent of total billed charges,,,77.7,,621.6,percent of total billed charges,,,95,,760,percent of total billed charges,,,60,,480,percent of total billed charges,,480,760,
OR 10030 IMAGE-GUIDED CATHETER FLUID COLLECTION DRAINAGE,36010030,CDM,360,RC,10030,CPT,,,Inpatient,,,800,,,,80,,640,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,621.6,percent of total billed charges,,,95,,760,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,760,
OR 25675 CLOSED TX DISTAL RADIOULNAR DISLOCATION W/MANJ,36025675,CDM,360,RC,25675,CPT,,,Outpatient,,,1200,,,,80,,960,percent of total billed charges,,,,50,404.51,fee schedule,,,77.7,,932.4,percent of total billed charges,,,95,,1140,percent of total billed charges,,,60,,720,percent of total billed charges,,720,1140,
OR 25675 CLOSED TX DISTAL RADIOULNAR DISLOCATION W/MANJ,36025675,CDM,360,RC,25675,CPT,,,Inpatient,,,1200,,,,80,,960,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,932.4,percent of total billed charges,,,95,,1140,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1140,
OR 30100 BIOPSY INTRANASAL,36030100,CDM,360,RC,30100,CPT,,,Outpatient,,,435,,,,80,,348,percent of total billed charges,,,,50,155.04,fee schedule,,,77.7,,338,percent of total billed charges,,,95,,413.25,percent of total billed charges,,,60,,261,percent of total billed charges,,261,413.25,
OR 30100 BIOPSY INTRANASAL,36030100,CDM,360,RC,30100,CPT,,,Inpatient,,,435,,,,80,,348,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,338,percent of total billed charges,,,95,,413.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,413.25,
OR 30930 FRACTURE NASAL INFERIOR TURBINATE THERAPEUTIC,36030930,CDM,360,RC,30930,CPT,,,Outpatient,,,1800,,,,80,,1440,percent of total billed charges,,,,50,309.06,fee schedule,,,77.7,,1398.6,percent of total billed charges,,,95,,1710,percent of total billed charges,,,60,,1080,percent of total billed charges,,1080,1710,
OR 30930 FRACTURE NASAL INFERIOR TURBINATE THERAPEUTIC,36030930,CDM,360,RC,30930,CPT,,,Inpatient,,,1800,,,,80,,1440,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1398.6,percent of total billed charges,,,95,,1710,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1710,
OR 42836 ADENOIDECTOMY SECONDARY AGE 12/>,36042836,CDM,360,RC,42836,CPT,,,Outpatient,,,2340,,,,80,,1872,percent of total billed charges,,,,50,899.91,fee schedule,,,77.7,,1818.18,percent of total billed charges,,,95,,2223,percent of total billed charges,,,60,,1404,percent of total billed charges,,1404,2223,
OR 42836 ADENOIDECTOMY SECONDARY AGE 12/>,36042836,CDM,360,RC,42836,CPT,,,Inpatient,,,2340,,,,80,,1872,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1818.18,percent of total billed charges,,,95,,2223,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2223,
OR 58353 ENDOMETRIAL ABLATION THERMAL,36058353,CDM,360,RC,58353,CPT,,,Outpatient,,,7200,,,,80,,5760,percent of total billed charges,,,,50,2798.12,fee schedule,,,77.7,,5594.4,percent of total billed charges,,,95,,6840,percent of total billed charges,,,60,,4320,percent of total billed charges,,4320,6840,
OR 58353 ENDOMETRIAL ABLATION THERMAL,36058353,CDM,360,RC,58353,CPT,,,Inpatient,,,7200,,,,80,,5760,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5594.4,percent of total billed charges,,,95,,6840,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6840,
OR 64417 INJ AXILLARY NERVE W/ IMAGING,36064417,CDM,360,RC,64417,CPT,,,Outpatient,,,450,,,,80,,360,percent of total billed charges,,,,50,155.04,fee schedule,,,77.7,,349.65,percent of total billed charges,,,95,,427.5,percent of total billed charges,,,60,,270,percent of total billed charges,,270,427.5,
OR 64417 INJ AXILLARY NERVE W/ IMAGING,36064417,CDM,360,RC,64417,CPT,,,Inpatient,,,450,,,,80,,360,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,349.65,percent of total billed charges,,,95,,427.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,427.5,
OR 64488 TAP BLOCK BILATERAL BY INJECTION(S),36064488,CDM,360,RC,64488,CPT,,,Outpatient,,,400,,,,80,,320,percent of total billed charges,,,,50,155.04,fee schedule,,,77.7,,310.8,percent of total billed charges,,,95,,380,percent of total billed charges,,,60,,240,percent of total billed charges,,240,380,
OR 64488 TAP BLOCK BILATERAL BY INJECTION(S),36064488,CDM,360,RC,64488,CPT,,,Inpatient,,,400,,,,80,,320,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,310.8,percent of total billed charges,,,95,,380,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,380,
OR 97607 NEG PRESSURE WOUND THERAPY NON DME </= 50 SQ CM,36097607,CDM,360,RC,97607,CPT,,,Outpatient,,,2228,,,,80,,1782.4,percent of total billed charges,,,,85,1893.8,percent of total billed charges,,,77.7,,1731.16,percent of total billed charges,,,95,,2116.6,percent of total billed charges,,,60,,1336.8,percent of total billed charges,,1336.8,2116.6,
OR 97607 NEG PRESSURE WOUND THERAPY NON DME </= 50 SQ CM,36097607,CDM,360,RC,97607,CPT,,,Inpatient,,,2228,,,,80,,1782.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1731.16,percent of total billed charges,,,95,,2116.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2116.6,
General Anesthesia 1st 15 Mins,37000000,CDM,370,RC,,,,,Outpatient,,,512,,,,80,,409.6,percent of total billed charges,,,,85,435.2,percent of total billed charges,,,77.7,,397.82,percent of total billed charges,,,95,,486.4,percent of total billed charges,,,60,,307.2,percent of total billed charges,,307.2,486.4,
General Anesthesia 1st 15 Mins,37000000,CDM,370,RC,,,,,Inpatient,,,512,,,,80,,409.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,397.82,percent of total billed charges,,,95,,486.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,486.4,
General Anesthesia ea addl 15 min,37000001,CDM,370,RC,,,,,Outpatient,,,195,,,,80,,156,percent of total billed charges,,,,85,165.75,percent of total billed charges,,,77.7,,151.52,percent of total billed charges,,,95,,185.25,percent of total billed charges,,,60,,117,percent of total billed charges,,117,185.25,
General Anesthesia ea addl 15 min,37000001,CDM,370,RC,,,,,Inpatient,,,195,,,,80,,156,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,151.52,percent of total billed charges,,,95,,185.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,185.25,
Monitored Anesthesia Care (MAC) 1st 15 Min,37000004,CDM,370,RC,,,,,Outpatient,,,512,,,,80,,409.6,percent of total billed charges,,,,85,435.2,percent of total billed charges,,,77.7,,397.82,percent of total billed charges,,,95,,486.4,percent of total billed charges,,,60,,307.2,percent of total billed charges,,307.2,486.4,
Monitored Anesthesia Care (MAC) 1st 15 Min,37000004,CDM,370,RC,,,,,Inpatient,,,512,,,,80,,409.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,397.82,percent of total billed charges,,,95,,486.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,486.4,
Monitored Anesthesia Care (MAC) ea addl 15 min,37000005,CDM,370,RC,,,,,Outpatient,,,195,,,,80,,156,percent of total billed charges,,,,85,165.75,percent of total billed charges,,,77.7,,151.52,percent of total billed charges,,,95,,185.25,percent of total billed charges,,,60,,117,percent of total billed charges,,117,185.25,
Monitored Anesthesia Care (MAC) ea addl 15 min,37000005,CDM,370,RC,,,,,Inpatient,,,195,,,,80,,156,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,151.52,percent of total billed charges,,,95,,185.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,185.25,
Spinal Anesthesia 1st 15 min,37000007,CDM,370,RC,,,,,Outpatient,,,512,,,,80,,409.6,percent of total billed charges,,,,85,435.2,percent of total billed charges,,,77.7,,397.82,percent of total billed charges,,,95,,486.4,percent of total billed charges,,,60,,307.2,percent of total billed charges,,307.2,486.4,
Spinal Anesthesia 1st 15 min,37000007,CDM,370,RC,,,,,Inpatient,,,512,,,,80,,409.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,397.82,percent of total billed charges,,,95,,486.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,486.4,
Spinal Anesthesia ea addl 15 min,37000008,CDM,370,RC,,,,,Outpatient,,,195,,,,80,,156,percent of total billed charges,,,,85,165.75,percent of total billed charges,,,77.7,,151.52,percent of total billed charges,,,95,,185.25,percent of total billed charges,,,60,,117,percent of total billed charges,,117,185.25,
Spinal Anesthesia ea addl 15 min,37000008,CDM,370,RC,,,,,Inpatient,,,195,,,,80,,156,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,151.52,percent of total billed charges,,,95,,185.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,185.25,
General TIVA Anesthesia Initial 15 Min,37000009,CDM,370,RC,,,,,Outpatient,,,512,,,,80,,409.6,percent of total billed charges,,,,85,435.2,percent of total billed charges,,,77.7,,397.82,percent of total billed charges,,,95,,486.4,percent of total billed charges,,,60,,307.2,percent of total billed charges,,307.2,486.4,
General TIVA Anesthesia Initial 15 Min,37000009,CDM,370,RC,,,,,Inpatient,,,512,,,,80,,409.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,397.82,percent of total billed charges,,,95,,486.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,486.4,
General TIVA Anesthesia addl 15 Min,37000010,CDM,370,RC,,,,,Outpatient,,,195,,,,80,,156,percent of total billed charges,,,,85,165.75,percent of total billed charges,,,77.7,,151.52,percent of total billed charges,,,95,,185.25,percent of total billed charges,,,60,,117,percent of total billed charges,,117,185.25,
General TIVA Anesthesia addl 15 Min,37000010,CDM,370,RC,,,,,Inpatient,,,195,,,,80,,156,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,151.52,percent of total billed charges,,,95,,185.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,185.25,
US Breast Left,40276641,CDM,402,RC,76641,CPT,,,Outpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,50,47.47,fee schedule,,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,60,,250.8,percent of total billed charges,,250.8,397.1,
US Breast Right,40276641,CDM,402,RC,76641,CPT,,,Outpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,50,47.47,fee schedule,,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,60,,250.8,percent of total billed charges,,250.8,397.1,
US Breast Left,40276641,CDM,402,RC,76641,CPT,,,Inpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,397.1,
US Breast Right,40276641,CDM,402,RC,76641,CPT,,,Inpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,397.1,
76705 US Gallbladder,40276705,CDM,402,RC,76705,CPT,,,Outpatient,,,439,,,,80,,351.2,percent of total billed charges,,,,50,58.58,fee schedule,,,77.7,,341.1,percent of total billed charges,,,95,,417.05,percent of total billed charges,,,60,,263.4,percent of total billed charges,,263.4,417.05,
US Gallbladder,40276705,CDM,402,RC,76705,CPT,,,Outpatient,,,439,,,,80,,351.2,percent of total billed charges,,,,50,58.58,fee schedule,,,77.7,,341.1,percent of total billed charges,,,95,,417.05,percent of total billed charges,,,60,,263.4,percent of total billed charges,,263.4,417.05,
76705 US Gallbladder,40276705,CDM,402,RC,76705,CPT,,,Inpatient,,,439,,,,80,,351.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,341.1,percent of total billed charges,,,95,,417.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,417.05,
US Gallbladder,40276705,CDM,402,RC,76705,CPT,,,Inpatient,,,439,,,,80,,351.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,341.1,percent of total billed charges,,,95,,417.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,417.05,
US AAA Screening,40276706,CDM,402,RC,76706,CPT,,,Outpatient,,,112,,,,80,,89.6,percent of total billed charges,,,,50,75.75,fee schedule,,,77.7,,87.02,percent of total billed charges,,,95,,106.4,percent of total billed charges,,,60,,67.2,percent of total billed charges,,67.2,106.4,
US AAA Screening,40276706,CDM,402,RC,76706,CPT,,,Inpatient,,,112,,,,80,,89.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,87.02,percent of total billed charges,,,95,,106.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,106.4,
US Echo Umbilical Artery,40276820,CDM,402,RC,76820,CPT,,,Outpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,85,355.3,percent of total billed charges,,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,60,,250.8,percent of total billed charges,,250.8,397.1,
US Echo Umbilical Artery,40276820,CDM,402,RC,76820,CPT,,,Inpatient,,,418,,,,80,,334.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,324.79,percent of total billed charges,,,95,,397.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,397.1,
US Pelvic & Transvaginal Non-OB,40276830,CDM,402,RC,76830,CPT,,,Outpatient,,,200,,,,80,,160,percent of total billed charges,,,,50,61.61,fee schedule,,,77.7,,155.4,percent of total billed charges,,,95,,190,percent of total billed charges,,,60,,120,percent of total billed charges,,120,190,
US Pelvic & Transvaginal Non-OB,40276830,CDM,402,RC,76830,CPT,,,Inpatient,,,200,,,,80,,160,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,155.4,percent of total billed charges,,,95,,190,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,190,
US LE Arterial Duplex Right,40293926,CDM,402,RC,93926,CPT,,,Outpatient,,,603,,,,80,,482.4,percent of total billed charges,,,,50,240.38,fee schedule,,,77.7,,468.53,percent of total billed charges,,,95,,572.85,percent of total billed charges,,,60,,361.8,percent of total billed charges,,361.8,572.85,
US LE Arterial Duplex Right,40293926,CDM,402,RC,93926,CPT,,,Inpatient,,,603,,,,80,,482.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,468.53,percent of total billed charges,,,95,,572.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,572.85,
US LE Venous Duplex Right,40293971,CDM,402,RC,93971,CPT,,,Outpatient,,,824,,,,80,,659.2,percent of total billed charges,,,,50,240.38,fee schedule,,,77.7,,640.25,percent of total billed charges,,,95,,782.8,percent of total billed charges,,,60,,494.4,percent of total billed charges,,494.4,782.8,
US LE Venous Duplex Right,40293971,CDM,402,RC,93971,CPT,,,Inpatient,,,824,,,,80,,659.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,640.25,percent of total billed charges,,,95,,782.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,782.8,
NT/ET Suctioning,41031720,CDM,410,RC,31720,CPT,,,Outpatient,,,875,,,,80,,700,percent of total billed charges,,,,50,346.43,fee schedule,,,77.7,,679.88,percent of total billed charges,,,95,,831.25,percent of total billed charges,,,60,,525,percent of total billed charges,,525,831.25,
NT/ET Suctioning,41031720,CDM,410,RC,31720,CPT,,,Inpatient,,,875,,,,80,,700,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,679.88,percent of total billed charges,,,95,,831.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,831.25,
ABG Drawing Fee,41036600,CDM,300,RC,36600,CPT,,,Outpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,50,33.84,fee schedule,,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,60,,157.06,percent of total billed charges,,157.06,248.68,
ABG Drawing Fee,41036600,CDM,300,RC,36600,CPT,,,Inpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,248.68,
SVN/MDI Treatment,41094640,CDM,410,RC,94640,CPT,,,Outpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,50,20.89,fee schedule,,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,60,,157.06,percent of total billed charges,,157.06,248.68,
SVN/MDI Treatment,41094640,CDM,410,RC,94640,CPT,,,Inpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,248.68,
PEP/Neb/IPPB/MDI Teaching,41094664,CDM,410,RC,94664,CPT,,,Outpatient,,,290,,,,80,,232,percent of total billed charges,,,,50,105.59,fee schedule,,,77.7,,225.33,percent of total billed charges,,,95,,275.5,percent of total billed charges,,,60,,174,percent of total billed charges,,174,275.5,
PEP/Neb/IPPB/MDI Teaching,41094664,CDM,410,RC,94664,CPT,,,Inpatient,,,290,,,,80,,232,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,225.33,percent of total billed charges,,,95,,275.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,275.5,
Chest Physiotherapy (CPT),41094667,CDM,410,RC,94667,CPT,,,Outpatient,,,261.37,,,,80,,209.1,percent of total billed charges,,,,85,222.16,percent of total billed charges,,,77.7,,203.08,percent of total billed charges,,,95,,248.3,percent of total billed charges,,,60,,156.82,percent of total billed charges,,156.82,248.3,
Chest Physiotherapy Initial,41094667,CDM,410,RC,94667,CPT,,,Outpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,85,222.5,percent of total billed charges,,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,60,,157.06,percent of total billed charges,,157.06,248.68,
Chest Physiotherapy (CPT),41094667,CDM,410,RC,94667,CPT,,,Inpatient,,,261.37,,,,80,,209.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,203.08,percent of total billed charges,,,95,,248.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,248.3,
Chest Physiotherapy Initial,41094667,CDM,410,RC,94667,CPT,,,Inpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,248.68,
Chest Physiotherapy Subsequent,41094668,CDM,410,RC,94668,CPT,,,Outpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,85,222.5,percent of total billed charges,,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,60,,157.06,percent of total billed charges,,157.06,248.68,
Chest Physiotherapy Subsequent,41094668,CDM,410,RC,94668,CPT,,,Inpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,248.68,
Single Pulse Ox,41094760,CDM,460,RC,94760,CPT,,,Outpatient,,,63,,,,80,,50.4,percent of total billed charges,,,,50,4.57,fee schedule,,,77.7,,48.95,percent of total billed charges,,,95,,59.85,percent of total billed charges,,,60,,37.8,percent of total billed charges,,37.8,59.85,
Single Pulse Ox,41094760,CDM,460,RC,94760,CPT,,,Inpatient,,,63,,,,80,,50.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,48.95,percent of total billed charges,,,95,,59.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,59.85,
Multiple Pulse Ox,41094761,CDM,460,RC,94761,CPT,,,Outpatient,,,142,,,,80,,113.6,percent of total billed charges,,,,50,8.57,fee schedule,,,77.7,,110.33,percent of total billed charges,,,95,,134.9,percent of total billed charges,,,60,,85.2,percent of total billed charges,,85.2,134.9,
Multiple Pulse Ox,41094761,CDM,460,RC,94761,CPT,,,Inpatient,,,142,,,,80,,113.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,110.33,percent of total billed charges,,,95,,134.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,134.9,
Overnight Pulse Ox,41094762,CDM,460,RC,94762,CPT,,,Outpatient,,,353,,,,80,,282.4,percent of total billed charges,,,,50,32.58,fee schedule,,,77.7,,274.28,percent of total billed charges,,,95,,335.35,percent of total billed charges,,,60,,211.8,percent of total billed charges,,211.8,335.35,
Overnight Pulse Ox,41094762,CDM,460,RC,94762,CPT,,,Inpatient,,,353,,,,80,,282.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,274.28,percent of total billed charges,,,95,,335.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,335.35,
Car Seat 60 minute Challenge,41094780,CDM,460,RC,94780,CPT,,,Outpatient,,,96,,,,80,,76.8,percent of total billed charges,,,,85,81.6,percent of total billed charges,,,77.7,,74.59,percent of total billed charges,,,95,,91.2,percent of total billed charges,,,60,,57.6,percent of total billed charges,,57.6,91.2,
Car Seat 60 minute Challenge,41094780,CDM,460,RC,94780,CPT,,,Inpatient,,,96,,,,80,,76.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,74.59,percent of total billed charges,,,95,,91.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,91.2,
Car Seat Addl 30 min Challenge,41094781,CDM,460,RC,94781,CPT,,,Outpatient,,,74,,,,80,,59.2,percent of total billed charges,,,,85,62.9,percent of total billed charges,,,77.7,,57.5,percent of total billed charges,,,95,,70.3,percent of total billed charges,,,60,,44.4,percent of total billed charges,,44.4,70.3,
Car Seat Addl 30 min Challenge,41094781,CDM,460,RC,94781,CPT,,,Inpatient,,,74,,,,80,,59.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,57.5,percent of total billed charges,,,95,,70.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,70.3,
CPM Daily CHK & ADJ (Specify) Units 97139,42097139,CDM,421,RC,97139,CPT,,,Outpatient,,,64,,GP,,80,,51.2,percent of total billed charges,,,,85,54.4,percent of total billed charges,,,77.7,,49.73,percent of total billed charges,,,95,,60.8,percent of total billed charges,,,60,,38.4,percent of total billed charges,,38.4,60.8,
CPM Daily CHK & ADJ (Specify) Units 97139,42097139,CDM,421,RC,97139,CPT,,,Inpatient,,,64,,GP,,80,,51.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,49.73,percent of total billed charges,,,95,,60.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,60.8,
Jobst Measure Units 97799,42097799,CDM,421,RC,97799,CPT,,,Outpatient,,,106,,GP,,80,,84.8,percent of total billed charges,,,,50,5.05,fee schedule,,,77.7,,82.36,percent of total billed charges,,,95,,100.7,percent of total billed charges,,,60,,63.6,percent of total billed charges,,63.6,100.7,
Jobst Measure Units 97799,42097799,CDM,421,RC,97799,CPT,,,Inpatient,,,106,,GP,,80,,84.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,82.36,percent of total billed charges,,,95,,100.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,100.7,
NM Hepatobiliary Scan and Function,44100011,CDM,341,RC,78227,CPT,,,Outpatient,,,1060,,,,80,,848,percent of total billed charges,,,,50,264.82,fee schedule,,,77.7,,823.62,percent of total billed charges,,,95,,1007,percent of total billed charges,,,60,,636,percent of total billed charges,,636,1007,
NM Hepatobiliary Scan and Function,44100011,CDM,341,RC,78227,CPT,,,Inpatient,,,1060,,,,80,,848,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,823.62,percent of total billed charges,,,95,,1007,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1007,
ER 10021 FNA BX W/O IMG GDN 1ST LES,45010021,CDM,450,RC,10021,CPT,,,Outpatient,,,885,,,,80,,708,percent of total billed charges,,,,85,752.25,percent of total billed charges,,,77.7,,687.65,percent of total billed charges,,,95,,840.75,percent of total billed charges,,,60,,531,percent of total billed charges,,531,840.75,
ER 10021 FNA BX W/O IMG GDN 1ST LES,45010021,CDM,450,RC,10021,CPT,,,Inpatient,,,885,,,,80,,708,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,687.65,percent of total billed charges,,,95,,840.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,840.75,
ER 10030 IMAGE-GUIDED CATHETER FLUID COLLECTION DRAINAGE,45010030,CDM,450,RC,10030,CPT,,,Outpatient,,,800,,,,80,,640,percent of total billed charges,,,,85,680,percent of total billed charges,,,77.7,,621.6,percent of total billed charges,,,95,,760,percent of total billed charges,,,60,,480,percent of total billed charges,,480,760,
ER 10030 IMAGE-GUIDED CATHETER FLUID COLLECTION DRAINAGE,45010030,CDM,450,RC,10030,CPT,,,Inpatient,,,800,,,,80,,640,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,621.6,percent of total billed charges,,,95,,760,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,760,
ER 10140 I&D HEMATOMA SEROMA/FLUID COLL,45010140,CDM,450,RC,10140,CPT,,,Outpatient,,,1490,,,,80,,1192,percent of total billed charges,,,,50,593.38,fee schedule,,,77.7,,1157.73,percent of total billed charges,,,95,,1415.5,percent of total billed charges,,,60,,894,percent of total billed charges,,894,1415.5,
ER 10140 I&D HEMATOMA SEROMA/FLUID COLL,45010140,CDM,450,RC,10140,CPT,,,Inpatient,,,1490,,,,80,,1192,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1157.73,percent of total billed charges,,,95,,1415.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1415.5,
ER 11042 DEBRIDE SUBQ TISSUE 20 SQ CM/<,45011042,CDM,450,RC,11042,CPT,,,Outpatient,,,365,,,,80,,292,percent of total billed charges,,,,50,225.59,fee schedule,,,77.7,,283.61,percent of total billed charges,,,95,,346.75,percent of total billed charges,,,60,,219,percent of total billed charges,,219,346.75,
ER 11042 DEBRIDE SUBQ TISSUE 20 SQ CM/<,45011042,CDM,450,RC,11042,CPT,,,Inpatient,,,365,,,,80,,292,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,283.61,percent of total billed charges,,,95,,346.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,346.75,
ER 13121 CMPLX RPR S/A/L 2.6-7.5 CM,45013121,CDM,450,RC,13121,CPT,,,Outpatient,,,950,,,,80,,760,percent of total billed charges,,,,50,269.67,fee schedule,,,77.7,,738.15,percent of total billed charges,,,95,,902.5,percent of total billed charges,,,60,,570,percent of total billed charges,,570,902.5,
ER 13121 CMPLX RPR S/A/L 2.6-7.5 CM,45013121,CDM,450,RC,13121,CPT,,,Inpatient,,,950,,,,80,,760,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,738.15,percent of total billed charges,,,95,,902.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,902.5,
ER 20552 INJ TRIGGER POINT 1 OR 2 MUSCL,45020552,CDM,450,RC,20552,CPT,,,Outpatient,,,435,,,,80,,348,percent of total billed charges,,,,50,165.27,fee schedule,,,77.7,,338,percent of total billed charges,,,95,,413.25,percent of total billed charges,,,60,,261,percent of total billed charges,,261,413.25,
ER 20552 INJ TRIGGER POINT 1 OR 2 MUSCL,45020552,CDM,450,RC,20552,CPT,,,Inpatient,,,435,,,,80,,348,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,338,percent of total billed charges,,,95,,413.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,413.25,
ER 25565  CLSD TRMT RAD/ULN SHAFT W/MAN,45025565,CDM,450,RC,25565,CPT,,,Outpatient,,,2028,,,,80,,1622.4,percent of total billed charges,,,,50,727.2,fee schedule,,,77.7,,1575.76,percent of total billed charges,,,95,,1926.6,percent of total billed charges,,,60,,1216.8,percent of total billed charges,,1216.8,1926.6,
ER 25565  CLSD TRMT RAD/ULN SHAFT W/MAN,45025565,CDM,450,RC,25565,CPT,,,Inpatient,,,2028,,,,80,,1622.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1575.76,percent of total billed charges,,,95,,1926.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1926.6,
ER 25675 CLSD TRMT DISTAL RAD DISLOC,45025675,CDM,450,RC,25675,CPT,,,Outpatient,,,1200,,,,80,,960,percent of total billed charges,,,,50,404.51,fee schedule,,,77.7,,932.4,percent of total billed charges,,,95,,1140,percent of total billed charges,,,60,,720,percent of total billed charges,,720,1140,
ER 25675 CLSD TRMT DISTAL RAD DISLOC,45025675,CDM,450,RC,25675,CPT,,,Inpatient,,,1200,,,,80,,960,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,932.4,percent of total billed charges,,,95,,1140,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1140,
ER 27810  CLSD TX ANKLE BIMALL FX W MN,45027810,CDM,450,RC,27810,CPT,,,Outpatient,,,1893,,,,80,,1514.4,percent of total billed charges,,,,50,727.2,fee schedule,,,77.7,,1470.86,percent of total billed charges,,,95,,1798.35,percent of total billed charges,,,60,,1135.8,percent of total billed charges,,1135.8,1798.35,
ER 27810  CLSD TX ANKLE BIMALL FX W MN,45027810,CDM,450,RC,27810,CPT,,,Inpatient,,,1893,,,,80,,1514.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1470.86,percent of total billed charges,,,95,,1798.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1798.35,
ER 27825 TREAT LOWER LEG FRACTURE,45027825,CDM,450,RC,27825,CPT,,,Outpatient,,,4320,,,,80,,3456,percent of total billed charges,,,,50,802.95,fee schedule,,,77.7,,3356.64,percent of total billed charges,,,95,,4104,percent of total billed charges,,,60,,2592,percent of total billed charges,,2592,4104,
ER 27825 TREAT LOWER LEG FRACTURE,45027825,CDM,450,RC,27825,CPT,,,Inpatient,,,4320,,,,80,,3456,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3356.64,percent of total billed charges,,,95,,4104,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4104,
ER 27840 TREAT ANKLE DISLOCATION,45027840,CDM,450,RC,27840,CPT,,,Outpatient,,,1048,,,,80,,838.4,percent of total billed charges,,,,50,404.51,fee schedule,,,77.7,,814.3,percent of total billed charges,,,95,,995.6,percent of total billed charges,,,60,,628.8,percent of total billed charges,,628.8,995.6,
ER 27840 TREAT ANKLE DISLOCATION,45027840,CDM,450,RC,27840,CPT,,,Inpatient,,,1048,,,,80,,838.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,814.3,percent of total billed charges,,,95,,995.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,995.6,
ER 27842  CLTX ANKLE DISLC W/ANES,45027842,CDM,450,RC,27842,CPT,,,Outpatient,,,1400,,,,80,,1120,percent of total billed charges,,,,50,538.84,fee schedule,,,77.7,,1087.8,percent of total billed charges,,,95,,1330,percent of total billed charges,,,60,,840,percent of total billed charges,,840,1330,
ER 27842  CLTX ANKLE DISLC W/ANES,45027842,CDM,450,RC,27842,CPT,,,Inpatient,,,1400,,,,80,,1120,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1087.8,percent of total billed charges,,,95,,1330,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1330,
ER 28630 CLTX METATARSOPHLNGL JT DISLC W/O ANES,45028630,CDM,450,RC,28630,CPT,,,Outpatient,,,1500,,,,80,,1200,percent of total billed charges,,,,50,404.51,fee schedule,,,77.7,,1165.5,percent of total billed charges,,,95,,1425,percent of total billed charges,,,60,,900,percent of total billed charges,,900,1425,
ER 28630 CLTX METATARSOPHLNGL JT DISLC W/O ANES,45028630,CDM,450,RC,28630,CPT,,,Inpatient,,,1500,,,,80,,1200,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1165.5,percent of total billed charges,,,95,,1425,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1425,
ER 29240 STRAPPING OF SHOULDER,45029240,CDM,450,RC,29240,CPT,,,Outpatient,,,425,,,,80,,340,percent of total billed charges,,,,50,138.88,fee schedule,,,77.7,,330.23,percent of total billed charges,,,95,,403.75,percent of total billed charges,,,60,,255,percent of total billed charges,,255,403.75,
ER 29240 STRAPPING OF SHOULDER,45029240,CDM,450,RC,29240,CPT,,,Inpatient,,,425,,,,80,,340,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,330.23,percent of total billed charges,,,95,,403.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,403.75,
ER 31231 NASAL ENDOSCOPY DIAGNOSTIC UNI/BI SPX,45031231,CDM,450,RC,31231,CPT,,,Outpatient,,,320,,,,80,,256,percent of total billed charges,,,,50,107.58,fee schedule,,,77.7,,248.64,percent of total billed charges,,,95,,304,percent of total billed charges,,,60,,192,percent of total billed charges,,192,304,
ER 31231 NASAL ENDOSCOPY DIAGNOSTIC UNI/BI SPX,45031231,CDM,450,RC,31231,CPT,,,Inpatient,,,320,,,,80,,256,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,248.64,percent of total billed charges,,,95,,304,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,304,
ER 31575 LARYNGOSCOPY FLEXIBLE DIAGNOSTIC,45031575,CDM,450,RC,31575,CPT,,,Outpatient,,,2250,,,,80,,1800,percent of total billed charges,,,,50,107.58,fee schedule,,,77.7,,1748.25,percent of total billed charges,,,95,,2137.5,percent of total billed charges,,,60,,1350,percent of total billed charges,,1350,2137.5,
ER 31575 LARYNGOSCOPY FLEXIBLE DIAGNOSTIC,45031575,CDM,450,RC,31575,CPT,,,Inpatient,,,2250,,,,80,,1800,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1748.25,percent of total billed charges,,,95,,2137.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2137.5,
ER 36430 BLOOD ADMIN 0-8HRS (PER DAY),45036430,CDM,450,RC,36430,CPT,,,Outpatient,,,668,,,,80,,534.4,percent of total billed charges,,,,50,257.85,fee schedule,,,77.7,,519.04,percent of total billed charges,,,95,,634.6,percent of total billed charges,,,60,,400.8,percent of total billed charges,,400.8,634.6,
ER 36430 BLOOD ADMIN 0-8HRS (PER DAY),45036430,CDM,450,RC,36430,CPT,,,Inpatient,,,668,,,,80,,534.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,519.04,percent of total billed charges,,,95,,634.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,634.6,
ER 42700 I&D ABSCESS PERITONSILLAR,45042700,CDM,450,RC,42700,CPT,,,Outpatient,,,544,,,,80,,435.2,percent of total billed charges,,,,85,462.4,percent of total billed charges,,,77.7,,422.69,percent of total billed charges,,,95,,516.8,percent of total billed charges,,,60,,326.4,percent of total billed charges,,326.4,516.8,
ER 42700 I&D ABSCESS PERITONSILLAR,45042700,CDM,450,RC,42700,CPT,,,Inpatient,,,544,,,,80,,435.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,422.69,percent of total billed charges,,,95,,516.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,516.8,
ER 42962 CTRL OROPHARYNGEAL HEMORRHAGE W/SEC SURG IVNTJ,45042962,CDM,450,RC,42962,CPT,,,Outpatient,,,5000,,,,80,,4000,percent of total billed charges,,,,50,1556.92,fee schedule,,,77.7,,3885,percent of total billed charges,,,95,,4750,percent of total billed charges,,,60,,3000,percent of total billed charges,,3000,4750,
ER 42962 CTRL OROPHARYNGEAL HEMORRHAGE W/SEC SURG IVNTJ,45042962,CDM,450,RC,42962,CPT,,,Inpatient,,,5000,,,,80,,4000,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3885,percent of total billed charges,,,95,,4750,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4750,
ER 46050 I&D PERIANAL ABSCESS SUPERFICIAL,45046050,CDM,450,RC,46050,CPT,,,Outpatient,,,1854,,,,80,,1483.2,percent of total billed charges,,,,50,459.55,fee schedule,,,77.7,,1440.56,percent of total billed charges,,,95,,1761.3,percent of total billed charges,,,60,,1112.4,percent of total billed charges,,1112.4,1761.3,
ER 46050 I&D PERIANAL ABSCESS SUPERFICIAL,45046050,CDM,450,RC,46050,CPT,,,Inpatient,,,1854,,,,80,,1483.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1440.56,percent of total billed charges,,,95,,1761.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1761.3,
ER 46060 I&D PERIRECTAL ABSCESS,45046060,CDM,450,RC,46060,CPT,,,Outpatient,,,3100,,,,80,,2480,percent of total billed charges,,,,85,2635,percent of total billed charges,,,77.7,,2408.7,percent of total billed charges,,,95,,2945,percent of total billed charges,,,60,,1860,percent of total billed charges,,1860,2945,
ER 46060 I&D PERIRECTAL ABSCESS,45046060,CDM,450,RC,46060,CPT,,,Inpatient,,,3100,,,,80,,2480,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2408.7,percent of total billed charges,,,95,,2945,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2945,
ER 49083 ER ABD PARACENTESIS W/IMAGING,45049083,CDM,450,RC,49083,CPT,,,Outpatient,,,1600,,,,80,,1280,percent of total billed charges,,,,50,347.95,fee schedule,,,77.7,,1243.2,percent of total billed charges,,,95,,1520,percent of total billed charges,,,60,,960,percent of total billed charges,,960,1520,
ER 49083 ER ABD PARACENTESIS W/IMAGING,45049083,CDM,450,RC,49083,CPT,,,Inpatient,,,1600,,,,80,,1280,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1243.2,percent of total billed charges,,,95,,1520,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1520,
ER 56420 I&D OF BARTHOLINS GLAND ABSCESS,45056420,CDM,450,RC,56420,CPT,,,Outpatient,,,252,,,,80,,201.6,percent of total billed charges,,,,85,214.2,percent of total billed charges,,,77.7,,195.8,percent of total billed charges,,,95,,239.4,percent of total billed charges,,,60,,151.2,percent of total billed charges,,151.2,239.4,
ER 56420 I&D OF BARTHOLINS GLAND ABSCESS,45056420,CDM,450,RC,56420,CPT,,,Inpatient,,,252,,,,80,,201.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,195.8,percent of total billed charges,,,95,,239.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,239.4,
ER 64405 INJECTION GREAT OCCIPITAL NERVE,45064405,CDM,450,RC,64405,CPT,,,Outpatient,,,587,,,,80,,469.6,percent of total billed charges,,,,50,159.58,fee schedule,,,77.7,,456.1,percent of total billed charges,,,95,,557.65,percent of total billed charges,,,60,,352.2,percent of total billed charges,,352.2,557.65,
ER 64405 INJECTION GREAT OCCIPITAL NERVE,45064405,CDM,450,RC,64405,CPT,,,Inpatient,,,587,,,,80,,469.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,456.1,percent of total billed charges,,,95,,557.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,557.65,
ER 64417 INJECTION AA&/STRD AXILLARY NERVE W/IMG GDN,45064417,CDM,450,RC,64417,CPT,,,Outpatient,,,450,,,,80,,360,percent of total billed charges,,,,50,155.04,fee schedule,,,77.7,,349.65,percent of total billed charges,,,95,,427.5,percent of total billed charges,,,60,,270,percent of total billed charges,,270,427.5,
ER 64417 INJECTION AA&/STRD AXILLARY NERVE W/IMG GDN,45064417,CDM,450,RC,64417,CPT,,,Inpatient,,,450,,,,80,,360,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,349.65,percent of total billed charges,,,95,,427.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,427.5,
ER 64505 INJECTION ANES AGENT SPHENOPALATINE GANGLION,45064505,CDM,450,RC,64505,CPT,,,Outpatient,,,1400,,,,80,,1120,percent of total billed charges,,,,50,491.87,fee schedule,,,77.7,,1087.8,percent of total billed charges,,,95,,1330,percent of total billed charges,,,60,,840,percent of total billed charges,,840,1330,
ER 64505 INJECTION ANES AGENT SPHENOPALATINE GANGLION,45064505,CDM,450,RC,64505,CPT,,,Inpatient,,,1400,,,,80,,1120,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1087.8,percent of total billed charges,,,95,,1330,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1330,
ER 65205 REM FRGN BODY EXT EYE SUPRF,45065205,CDM,450,RC,65205,CPT,,,Outpatient,,,434,,,,80,,347.2,percent of total billed charges,,,,50,155.04,fee schedule,,,77.7,,337.22,percent of total billed charges,,,95,,412.3,percent of total billed charges,,,60,,260.4,percent of total billed charges,,260.4,412.3,
ER 65205 REM FRGN BODY EXT EYE SUPRF,45065205,CDM,450,RC,65205,CPT,,,Inpatient,,,434,,,,80,,347.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,337.22,percent of total billed charges,,,95,,412.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,412.3,
ER 69209 REMOVE IMPACTED EAR WAX UNI,45069209,CDM,450,RC,69209,CPT,,,Outpatient,,,640,,,,80,,512,percent of total billed charges,,,,50,293.25,fee schedule,,,77.7,,497.28,percent of total billed charges,,,95,,608,percent of total billed charges,,,60,,384,percent of total billed charges,,384,608,
ER 69209 REMOVE IMPACTED EAR WAX UNI,45069209,CDM,450,RC,69209,CPT,,,Inpatient,,,640,,,,80,,512,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,497.28,percent of total billed charges,,,95,,608,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,608,
ER 90471 IMMUNIZATION ADMIN ONE VACCINE,45090471,CDM,450,RC,90471,CPT,,,Outpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,50,4.04,fee schedule,,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,60,,157.06,percent of total billed charges,,157.06,248.68,
ER 90471 IMMUNIZATION ADMIN ONE VACCINE,45090471,CDM,450,RC,90471,CPT,,,Inpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,248.68,
ER 90472 IMMUNIZATION ADMIN ADDL VACC,45090472,CDM,450,RC,90472,CPT,,,Outpatient,,,20,,,,80,,16,percent of total billed charges,,,,50,4.04,fee schedule,,,77.7,,15.54,percent of total billed charges,,,95,,19,percent of total billed charges,,,60,,12,percent of total billed charges,,12,19,
ER 90472 IMMUNIZATION ADMIN ADDL VACC,45090472,CDM,450,RC,90472,CPT,,,Inpatient,,,20,,,,80,,16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,15.54,percent of total billed charges,,,95,,19,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,19,
ER 92977 THROMBOLYSIS CORONARY BY IV,45092977,CDM,450,RC,92977,CPT,,,Outpatient,,,945,,,,80,,756,percent of total billed charges,,,,50,371.18,fee schedule,,,77.7,,734.27,percent of total billed charges,,,95,,897.75,percent of total billed charges,,,60,,567,percent of total billed charges,,567,897.75,
ER 92977 THROMBOLYSIS CORONARY BY IV,45092977,CDM,450,RC,92977,CPT,,,Inpatient,,,945,,,,80,,756,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,734.27,percent of total billed charges,,,95,,897.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,897.75,
ER 95992 CANALITH REPOSITIONING PROCEDURE PER DAY,45095992,CDM,450,RC,95992,CPT,,,Outpatient,,,56,,,,80,,44.8,percent of total billed charges,,,,50,20.07,fee schedule,,,77.7,,43.51,percent of total billed charges,,,95,,53.2,percent of total billed charges,,,60,,33.6,percent of total billed charges,,33.6,53.2,
ER 95992 CANALITH REPOSITIONING PROCEDURE PER DAY,45095992,CDM,450,RC,95992,CPT,,,Inpatient,,,56,,,,80,,44.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,43.51,percent of total billed charges,,,95,,53.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,53.2,
6 Minute Walk - Pulmonary Rehab,46094618,CDM,460,RC,94618,CPT,,,Outpatient,,,193,,,,80,,154.4,percent of total billed charges,,,,50,62.12,fee schedule,,,77.7,,149.96,percent of total billed charges,,,95,,183.35,percent of total billed charges,,,60,,115.8,percent of total billed charges,,115.8,183.35,
6 Minute Walk - Pulmonary Rehab,46094618,CDM,460,RC,94618,CPT,,,Inpatient,,,193,,,,80,,154.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,149.96,percent of total billed charges,,,95,,183.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,183.35,
PF Bronchospasm without ECG,46094619,CDM,460,RC,94619,CPT,,,Outpatient,,,410,,,,80,,328,percent of total billed charges,,,,85,348.5,percent of total billed charges,,,77.7,,318.57,percent of total billed charges,,,95,,389.5,percent of total billed charges,,,60,,246,percent of total billed charges,,246,389.5,
PF Bronchospasm without ECG,46094619,CDM,460,RC,94619,CPT,,,Inpatient,,,410,,,,80,,328,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,318.57,percent of total billed charges,,,95,,389.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,389.5,
Newborn Hearing Screen Charge,47092587,CDM,470,RC,92587,CPT,,,Outpatient,,,271,,,,80,,216.8,percent of total billed charges,,,,50,28.17,fee schedule,,,77.7,,210.57,percent of total billed charges,,,95,,257.45,percent of total billed charges,,,60,,162.6,percent of total billed charges,,162.6,257.45,
Newborn Hearing Screen Charge,47092587,CDM,470,RC,92587,CPT,,,Inpatient,,,271,,,,80,,216.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,210.57,percent of total billed charges,,,95,,257.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,257.45,
US Echo Doppler Complete,48093306,CDM,483,RC,93306,CPT,,,Outpatient,,,2179,,,,80,,1743.2,percent of total billed charges,,,,50,766.09,fee schedule,,,77.7,,1693.08,percent of total billed charges,,,95,,2070.05,percent of total billed charges,,,60,,1307.4,percent of total billed charges,,1307.4,2070.05,
US Echo Doppler Complete,48093306,CDM,483,RC,93306,CPT,,,Inpatient,,,2179,,,,80,,1743.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1693.08,percent of total billed charges,,,95,,2070.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2070.05,
MRI TMJ,61070336,CDM,610,RC,70336,CPT,,,Outpatient,,,1300,,,,80,,1040,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1010.1,percent of total billed charges,,,95,,1235,percent of total billed charges,,,60,,780,percent of total billed charges,,780,1235,
MRI TMJ,61070336,CDM,610,RC,70336,CPT,,,Inpatient,,,1300,,,,80,,1040,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1010.1,percent of total billed charges,,,95,,1235,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1235,
MRI Face Neck Orbit w/ + w/o Contrast,61070543,CDM,610,RC,70543,CPT,,,Outpatient,,,1450,,,,80,,1160,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1126.65,percent of total billed charges,,,95,,1377.5,percent of total billed charges,,,60,,870,percent of total billed charges,,870,1377.5,
MRI Face Neck Orbit w/ + w/o Contrast,61070543,CDM,610,RC,70543,CPT,,,Inpatient,,,1450,,,,80,,1160,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1126.65,percent of total billed charges,,,95,,1377.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1377.5,
MRI Brain w/ Contrast,61070552,CDM,610,RC,70552,CPT,,,Outpatient,,,1500,,,,80,,1200,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1165.5,percent of total billed charges,,,95,,1425,percent of total billed charges,,,60,,900,percent of total billed charges,,900,1425,
MRI Brain w/ Contrast,61070552,CDM,610,RC,70552,CPT,,,Inpatient,,,1500,,,,80,,1200,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1165.5,percent of total billed charges,,,95,,1425,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1425,
MRI Chest w/o Contrast,61071550,CDM,610,RC,71550,CPT,,,Outpatient,,,1300,,,,80,,1040,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1010.1,percent of total billed charges,,,95,,1235,percent of total billed charges,,,60,,780,percent of total billed charges,,780,1235,
MRI Chest w/o Contrast,61071550,CDM,610,RC,71550,CPT,,,Inpatient,,,1300,,,,80,,1040,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1010.1,percent of total billed charges,,,95,,1235,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1235,
MRI Chest w/ Contrast,61071551,CDM,610,RC,71551,CPT,,,Outpatient,,,1375,,,,80,,1100,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1068.38,percent of total billed charges,,,95,,1306.25,percent of total billed charges,,,60,,825,percent of total billed charges,,825,1306.25,
MRI Chest w/ Contrast,61071551,CDM,610,RC,71551,CPT,,,Inpatient,,,1375,,,,80,,1100,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1068.38,percent of total billed charges,,,95,,1306.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1306.25,
MRI Chest w/ + w/o Contrast,61071552,CDM,610,RC,71552,CPT,,,Outpatient,,,1450,,,,80,,1160,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1126.65,percent of total billed charges,,,95,,1377.5,percent of total billed charges,,,60,,870,percent of total billed charges,,870,1377.5,
MRI Chest w/ + w/o Contrast,61071552,CDM,610,RC,71552,CPT,,,Inpatient,,,1450,,,,80,,1160,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1126.65,percent of total billed charges,,,95,,1377.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1377.5,
MRA Chest w/ + w/o Contrast,61071555,CDM,610,RC,71555,CPT,,,Outpatient,,,900,,,,80,,720,percent of total billed charges,,,,50,316.64,fee schedule,,,77.7,,699.3,percent of total billed charges,,,95,,855,percent of total billed charges,,,60,,540,percent of total billed charges,,540,855,
MRA Chest w/ + w/o Contrast,61071555,CDM,610,RC,71555,CPT,,,Inpatient,,,900,,,,80,,720,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,699.3,percent of total billed charges,,,95,,855,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,855,
MRI Spine Cervical w/ Contrast,61072142,CDM,610,RC,72142,CPT,,,Outpatient,,,1375,,,,80,,1100,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1068.38,percent of total billed charges,,,95,,1306.25,percent of total billed charges,,,60,,825,percent of total billed charges,,825,1306.25,
MRI Spine Cervical w/ Contrast,61072142,CDM,610,RC,72142,CPT,,,Inpatient,,,1375,,,,80,,1100,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1068.38,percent of total billed charges,,,95,,1306.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1306.25,
MRI Spine Thoracic w/ Contrast,61072147,CDM,610,RC,72147,CPT,,,Outpatient,,,1375,,,,80,,1100,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1068.38,percent of total billed charges,,,95,,1306.25,percent of total billed charges,,,60,,825,percent of total billed charges,,825,1306.25,
MRI Spine Thoracic w/ Contrast,61072147,CDM,610,RC,72147,CPT,,,Inpatient,,,1375,,,,80,,1100,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1068.38,percent of total billed charges,,,95,,1306.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1306.25,
MRI Spine Lumbar w/ Contrast,61072149,CDM,610,RC,72149,CPT,,,Outpatient,,,1375,,,,80,,1100,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1068.38,percent of total billed charges,,,95,,1306.25,percent of total billed charges,,,60,,825,percent of total billed charges,,825,1306.25,
MRI Spine Lumbar w/ Contrast,61072149,CDM,610,RC,72149,CPT,,,Inpatient,,,1375,,,,80,,1100,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1068.38,percent of total billed charges,,,95,,1306.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1306.25,
MRA Pelvis w/ + w/o Contrast,61072198,CDM,610,RC,72198,CPT,,,Outpatient,,,900,,,,80,,720,percent of total billed charges,,,,50,316.64,fee schedule,,,77.7,,699.3,percent of total billed charges,,,95,,855,percent of total billed charges,,,60,,540,percent of total billed charges,,540,855,
MRA Pelvis w/ + w/o Contrast,61072198,CDM,610,RC,72198,CPT,,,Inpatient,,,900,,,,80,,720,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,699.3,percent of total billed charges,,,95,,855,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,855,
MRI UE Non Joint w/o Contrast Right,61073218,CDM,610,RC,73218,CPT,,,Outpatient,,,1300,,,,80,,1040,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1010.1,percent of total billed charges,,,95,,1235,percent of total billed charges,,,60,,780,percent of total billed charges,,780,1235,
MRI UE Non Joint w/o Contrast Right,61073218,CDM,610,RC,73218,CPT,,,Inpatient,,,1300,,,,80,,1040,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1010.1,percent of total billed charges,,,95,,1235,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1235,
MRI UE Non Joint w/ Contrast Left,61073219,CDM,610,RC,73219,CPT,,,Outpatient,,,1375,,,,80,,1100,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1068.38,percent of total billed charges,,,95,,1306.25,percent of total billed charges,,,60,,825,percent of total billed charges,,825,1306.25,
MRI UE Non Joint w/ Contrast Right,61073219,CDM,610,RC,73219,CPT,,,Outpatient,,,1375,,,,80,,1100,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1068.38,percent of total billed charges,,,95,,1306.25,percent of total billed charges,,,60,,825,percent of total billed charges,,825,1306.25,
MRI UE Non Joint w/ Contrast Left,61073219,CDM,610,RC,73219,CPT,,,Inpatient,,,1375,,,,80,,1100,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1068.38,percent of total billed charges,,,95,,1306.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1306.25,
MRI UE Non Joint w/ Contrast Right,61073219,CDM,610,RC,73219,CPT,,,Inpatient,,,1375,,,,80,,1100,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1068.38,percent of total billed charges,,,95,,1306.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1306.25,
MRI UE Joint w/o Contrast Right,61073221,CDM,610,RC,73221,CPT,,,Outpatient,,,1655,,,,80,,1324,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1285.94,percent of total billed charges,,,95,,1572.25,percent of total billed charges,,,60,,993,percent of total billed charges,,993,1572.25,
MRI UE Joint w/o Contrast Right,61073221,CDM,610,RC,73221,CPT,,,Inpatient,,,1655,,,,80,,1324,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1285.94,percent of total billed charges,,,95,,1572.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1572.25,
MRI UE Joint w/ Contrast Left,61073222,CDM,610,RC,73222,CPT,,,Outpatient,,,1375,,,,80,,1100,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1068.38,percent of total billed charges,,,95,,1306.25,percent of total billed charges,,,60,,825,percent of total billed charges,,825,1306.25,
MRI UE Joint w/ Contrast Right,61073222,CDM,610,RC,73222,CPT,,,Outpatient,,,1375,,,,80,,1100,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1068.38,percent of total billed charges,,,95,,1306.25,percent of total billed charges,,,60,,825,percent of total billed charges,,825,1306.25,
MRI UE Joint w/ Contrast Left,61073222,CDM,610,RC,73222,CPT,,,Inpatient,,,1375,,,,80,,1100,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1068.38,percent of total billed charges,,,95,,1306.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1306.25,
MRI UE Joint w/ Contrast Right,61073222,CDM,610,RC,73222,CPT,,,Inpatient,,,1375,,,,80,,1100,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1068.38,percent of total billed charges,,,95,,1306.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1306.25,
MRI UE Joint w/ + w/o Contrast Left,61073223,CDM,610,RC,73223,CPT,,,Outpatient,,,1450,,,,80,,1160,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1126.65,percent of total billed charges,,,95,,1377.5,percent of total billed charges,,,60,,870,percent of total billed charges,,870,1377.5,
MRI UE Joint w/ + w/o Contrast Right,61073223,CDM,610,RC,73223,CPT,,,Outpatient,,,1450,,,,80,,1160,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1126.65,percent of total billed charges,,,95,,1377.5,percent of total billed charges,,,60,,870,percent of total billed charges,,870,1377.5,
MRI UE Joint w/ + w/o Contrast Left,61073223,CDM,610,RC,73223,CPT,,,Inpatient,,,1450,,,,80,,1160,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1126.65,percent of total billed charges,,,95,,1377.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1377.5,
MRI UE Joint w/ + w/o Contrast Right,61073223,CDM,610,RC,73223,CPT,,,Inpatient,,,1450,,,,80,,1160,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1126.65,percent of total billed charges,,,95,,1377.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1377.5,
MRI LE Non Joint w/o Contrast Left,61073718,CDM,610,RC,73718,CPT,,,Outpatient,,,1300,,,,80,,1040,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1010.1,percent of total billed charges,,,95,,1235,percent of total billed charges,,,60,,780,percent of total billed charges,,780,1235,
MRI LE Non Joint w/o Contrast Right,61073718,CDM,610,RC,73718,CPT,,,Outpatient,,,1300,,,,80,,1040,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1010.1,percent of total billed charges,,,95,,1235,percent of total billed charges,,,60,,780,percent of total billed charges,,780,1235,
MRI LE Non Joint w/o Contrast Left,61073718,CDM,610,RC,73718,CPT,,,Inpatient,,,1300,,,,80,,1040,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1010.1,percent of total billed charges,,,95,,1235,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1235,
MRI LE Non Joint w/o Contrast Right,61073718,CDM,610,RC,73718,CPT,,,Inpatient,,,1300,,,,80,,1040,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1010.1,percent of total billed charges,,,95,,1235,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1235,
MRI LE Non Joint w/ Contrast Left,61073719,CDM,610,RC,73719,CPT,,,Outpatient,,,1375,,,,80,,1100,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1068.38,percent of total billed charges,,,95,,1306.25,percent of total billed charges,,,60,,825,percent of total billed charges,,825,1306.25,
MRI LE Non Joint w/ Contrast Right,61073719,CDM,610,RC,73719,CPT,,,Outpatient,,,1375,,,,80,,1100,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1068.38,percent of total billed charges,,,95,,1306.25,percent of total billed charges,,,60,,825,percent of total billed charges,,825,1306.25,
MRI LE Non Joint w/ Contrast Left,61073719,CDM,610,RC,73719,CPT,,,Inpatient,,,1375,,,,80,,1100,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1068.38,percent of total billed charges,,,95,,1306.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1306.25,
MRI LE Non Joint w/ Contrast Right,61073719,CDM,610,RC,73719,CPT,,,Inpatient,,,1375,,,,80,,1100,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1068.38,percent of total billed charges,,,95,,1306.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1306.25,
MRI LE Non Joint w/ + w/o Contrast Left,61073720,CDM,610,RC,73720,CPT,,,Outpatient,,,1450,,,,80,,1160,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1126.65,percent of total billed charges,,,95,,1377.5,percent of total billed charges,,,60,,870,percent of total billed charges,,870,1377.5,
MRI LE Non Joint w/ + w/o Contrast Right,61073720,CDM,610,RC,73720,CPT,,,Outpatient,,,1450,,,,80,,1160,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1126.65,percent of total billed charges,,,95,,1377.5,percent of total billed charges,,,60,,870,percent of total billed charges,,870,1377.5,
MRI UE Non Joint w/ + w/o Contrast Left,61073720,CDM,610,RC,73720,CPT,,,Outpatient,,,1450,,,,80,,1160,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1126.65,percent of total billed charges,,,95,,1377.5,percent of total billed charges,,,60,,870,percent of total billed charges,,870,1377.5,
MRI UE Non Joint w/ + w/o Contrast Right,61073720,CDM,610,RC,73720,CPT,,,Outpatient,,,1450,,,,80,,1160,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1126.65,percent of total billed charges,,,95,,1377.5,percent of total billed charges,,,60,,870,percent of total billed charges,,870,1377.5,
MRI LE Non Joint w/ + w/o Contrast Left,61073720,CDM,610,RC,73720,CPT,,,Inpatient,,,1450,,,,80,,1160,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1126.65,percent of total billed charges,,,95,,1377.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1377.5,
MRI LE Non Joint w/ + w/o Contrast Right,61073720,CDM,610,RC,73720,CPT,,,Inpatient,,,1450,,,,80,,1160,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1126.65,percent of total billed charges,,,95,,1377.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1377.5,
MRI UE Non Joint w/ + w/o Contrast Left,61073720,CDM,610,RC,73720,CPT,,,Inpatient,,,1450,,,,80,,1160,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1126.65,percent of total billed charges,,,95,,1377.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1377.5,
MRI UE Non Joint w/ + w/o Contrast Right,61073720,CDM,610,RC,73720,CPT,,,Inpatient,,,1450,,,,80,,1160,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1126.65,percent of total billed charges,,,95,,1377.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1377.5,
MRI LE Joint w/o Contrast Left,61073721,CDM,610,RC,73721,CPT,,,Outpatient,,,1300,,,,80,,1040,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1010.1,percent of total billed charges,,,95,,1235,percent of total billed charges,,,60,,780,percent of total billed charges,,780,1235,
MRI LE Joint w/o Contrast Right,61073721,CDM,610,RC,73721,CPT,,,Outpatient,,,1300,,,,80,,1040,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1010.1,percent of total billed charges,,,95,,1235,percent of total billed charges,,,60,,780,percent of total billed charges,,780,1235,
MRI LE Joint w/o Contrast Left,61073721,CDM,610,RC,73721,CPT,,,Inpatient,,,1300,,,,80,,1040,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1010.1,percent of total billed charges,,,95,,1235,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1235,
MRI LE Joint w/o Contrast Right,61073721,CDM,610,RC,73721,CPT,,,Inpatient,,,1300,,,,80,,1040,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1010.1,percent of total billed charges,,,95,,1235,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1235,
MRI LE Joint w/ Contrast Left,61073722,CDM,610,RC,73722,CPT,,,Outpatient,,,1375,,,,80,,1100,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1068.38,percent of total billed charges,,,95,,1306.25,percent of total billed charges,,,60,,825,percent of total billed charges,,825,1306.25,
MRI LE Joint w/ Contrast Right,61073722,CDM,610,RC,73722,CPT,,,Outpatient,,,1375,,,,80,,1100,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1068.38,percent of total billed charges,,,95,,1306.25,percent of total billed charges,,,60,,825,percent of total billed charges,,825,1306.25,
MRI LE Joint w/ Contrast Left,61073722,CDM,610,RC,73722,CPT,,,Inpatient,,,1375,,,,80,,1100,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1068.38,percent of total billed charges,,,95,,1306.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1306.25,
MRI LE Joint w/ Contrast Right,61073722,CDM,610,RC,73722,CPT,,,Inpatient,,,1375,,,,80,,1100,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1068.38,percent of total billed charges,,,95,,1306.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1306.25,
MRI LE Joint w/ + w/o Contrast Left,61073723,CDM,610,RC,73723,CPT,,,Outpatient,,,1450,,,,80,,1160,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1126.65,percent of total billed charges,,,95,,1377.5,percent of total billed charges,,,60,,870,percent of total billed charges,,870,1377.5,
MRI LE Joint w/ + w/o Contrast Right,61073723,CDM,610,RC,73723,CPT,,,Outpatient,,,1450,,,,80,,1160,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,1126.65,percent of total billed charges,,,95,,1377.5,percent of total billed charges,,,60,,870,percent of total billed charges,,870,1377.5,
MRI LE Joint w/ + w/o Contrast Left,61073723,CDM,610,RC,73723,CPT,,,Inpatient,,,1450,,,,80,,1160,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1126.65,percent of total billed charges,,,95,,1377.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1377.5,
MRI LE Joint w/ + w/o Contrast Right,61073723,CDM,610,RC,73723,CPT,,,Inpatient,,,1450,,,,80,,1160,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1126.65,percent of total billed charges,,,95,,1377.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1377.5,
MRA Abdomen w/ + w/o Contrast,61074185,CDM,610,RC,74185,CPT,,,Outpatient,,,900,,,,80,,720,percent of total billed charges,,,,50,316.64,fee schedule,,,77.7,,699.3,percent of total billed charges,,,95,,855,percent of total billed charges,,,60,,540,percent of total billed charges,,540,855,
MRA Abdomen w/ + w/o Contrast,61074185,CDM,610,RC,74185,CPT,,,Inpatient,,,900,,,,80,,720,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,699.3,percent of total billed charges,,,95,,855,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,855,
MRI Breast w/o Contrast Left,61077046,CDM,610,RC,77046,CPT,,,Outpatient,,,800,,,,80,,640,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,621.6,percent of total billed charges,,,95,,760,percent of total billed charges,,,60,,480,percent of total billed charges,,480,760,
MRI Breast w/o Contrast Right,61077046,CDM,610,RC,77046,CPT,,,Outpatient,,,800,,,,80,,640,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,621.6,percent of total billed charges,,,95,,760,percent of total billed charges,,,60,,480,percent of total billed charges,,480,760,
MRI Breast w/o Contrast Left,61077046,CDM,610,RC,77046,CPT,,,Inpatient,,,800,,,,80,,640,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,621.6,percent of total billed charges,,,95,,760,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,760,
MRI Breast w/o Contrast Right,61077046,CDM,610,RC,77046,CPT,,,Inpatient,,,800,,,,80,,640,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,621.6,percent of total billed charges,,,95,,760,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,760,
MRI Breast w/o Contrast Bilateral,61077047,CDM,610,RC,77047,CPT,,,Outpatient,,,800,,,,80,,640,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,621.6,percent of total billed charges,,,95,,760,percent of total billed charges,,,60,,480,percent of total billed charges,,480,760,
MRI Breast w/o Contrast Bilateral,61077047,CDM,610,RC,77047,CPT,,,Inpatient,,,800,,,,80,,640,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,621.6,percent of total billed charges,,,95,,760,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,760,
MRI Breast w/ + w/o Contrast Left,61077048,CDM,610,RC,77048,CPT,,,Outpatient,,,800,,,,80,,640,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,621.6,percent of total billed charges,,,95,,760,percent of total billed charges,,,60,,480,percent of total billed charges,,480,760,
MRI Breast w/ + w/o Contrast Right,61077048,CDM,610,RC,77048,CPT,,,Outpatient,,,800,,,,80,,640,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,621.6,percent of total billed charges,,,95,,760,percent of total billed charges,,,60,,480,percent of total billed charges,,480,760,
MRI Breast w/ + w/o Contrast Left,61077048,CDM,610,RC,77048,CPT,,,Inpatient,,,800,,,,80,,640,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,621.6,percent of total billed charges,,,95,,760,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,760,
MRI Breast w/ + w/o Contrast Right,61077048,CDM,610,RC,77048,CPT,,,Inpatient,,,800,,,,80,,640,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,621.6,percent of total billed charges,,,95,,760,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,760,
MRI Breast w/ + w/o Contrast Bilateral,61077049,CDM,610,RC,77049,CPT,,,Outpatient,,,800,,,,80,,640,percent of total billed charges,,,,50,263.11,fee schedule,,,77.7,,621.6,percent of total billed charges,,,95,,760,percent of total billed charges,,,60,,480,percent of total billed charges,,480,760,
MRI Breast w/ + w/o Contrast Bilateral,61077049,CDM,610,RC,77049,CPT,,,Inpatient,,,800,,,,80,,640,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,621.6,percent of total billed charges,,,95,,760,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,760,
MRA Head w/o Contrast,61570544,CDM,615,RC,70544,CPT,,,Outpatient,,,1475,,,,80,,1180,percent of total billed charges,,,,50,316.64,fee schedule,,,77.7,,1146.08,percent of total billed charges,,,95,,1401.25,percent of total billed charges,,,60,,885,percent of total billed charges,,885,1401.25,
MRA Head w/o Contrast,61570544,CDM,615,RC,70544,CPT,,,Inpatient,,,1475,,,,80,,1180,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1146.08,percent of total billed charges,,,95,,1401.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1401.25,
MRA Head w/ Contrast,61570545,CDM,615,RC,70545,CPT,,,Outpatient,,,1550,,,,80,,1240,percent of total billed charges,,,,50,316.64,fee schedule,,,77.7,,1204.35,percent of total billed charges,,,95,,1472.5,percent of total billed charges,,,60,,930,percent of total billed charges,,930,1472.5,
MRA Head w/ Contrast,61570545,CDM,615,RC,70545,CPT,,,Inpatient,,,1550,,,,80,,1240,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1204.35,percent of total billed charges,,,95,,1472.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1472.5,
MRA Head w/ + w/o Contrast,61570546,CDM,615,RC,70546,CPT,,,Outpatient,,,1625,,,,80,,1300,percent of total billed charges,,,,50,316.64,fee schedule,,,77.7,,1262.63,percent of total billed charges,,,95,,1543.75,percent of total billed charges,,,60,,975,percent of total billed charges,,975,1543.75,
MRA Head w/ + w/o Contrast,61570546,CDM,615,RC,70546,CPT,,,Inpatient,,,1625,,,,80,,1300,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1262.63,percent of total billed charges,,,95,,1543.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1543.75,
MRA Neck w/o Contrast,61570547,CDM,615,RC,70547,CPT,,,Outpatient,,,900,,TC,,80,,720,percent of total billed charges,,,,50,316.64,fee schedule,,,77.7,,699.3,percent of total billed charges,,,95,,855,percent of total billed charges,,,60,,540,percent of total billed charges,,540,855,
MRA Neck w/o Contrast,61570547,CDM,615,RC,70547,CPT,,,Inpatient,,,900,,TC,,80,,720,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,699.3,percent of total billed charges,,,95,,855,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,855,
MRA Neck w/ Contrast,61570548,CDM,615,RC,70548,CPT,,,Outpatient,,,900,,,,80,,720,percent of total billed charges,,,,50,316.64,fee schedule,,,77.7,,699.3,percent of total billed charges,,,95,,855,percent of total billed charges,,,60,,540,percent of total billed charges,,540,855,
MRA Neck w/ Contrast,61570548,CDM,615,RC,70548,CPT,,,Inpatient,,,900,,,,80,,720,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,699.3,percent of total billed charges,,,95,,855,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,855,
MRA Neck w/ + w/o Contrast,61570549,CDM,615,RC,70549,CPT,,,Outpatient,,,900,,,,80,,720,percent of total billed charges,,,,50,316.64,fee schedule,,,77.7,,699.3,percent of total billed charges,,,95,,855,percent of total billed charges,,,60,,540,percent of total billed charges,,540,855,
MRA Neck w/ + w/o Contrast,61570549,CDM,615,RC,70549,CPT,,,Inpatient,,,900,,,,80,,720,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,699.3,percent of total billed charges,,,95,,855,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,855,
MRA Lower Extremity w/ + w/o Left,61673725,CDM,616,RC,73725,CPT,,,Outpatient,,,900,,,,80,,720,percent of total billed charges,,,,50,316.64,fee schedule,,,77.7,,699.3,percent of total billed charges,,,95,,855,percent of total billed charges,,,60,,540,percent of total billed charges,,540,855,
MRA Lower Extremity w/ + w/o Right,61673725,CDM,616,RC,73725,CPT,,,Outpatient,,,900,,,,80,,720,percent of total billed charges,,,,50,316.64,fee schedule,,,77.7,,699.3,percent of total billed charges,,,95,,855,percent of total billed charges,,,60,,540,percent of total billed charges,,540,855,
MRA Lower Extremity w/ + w/o Left,61673725,CDM,616,RC,73725,CPT,,,Inpatient,,,900,,,,80,,720,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,699.3,percent of total billed charges,,,95,,855,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,855,
MRA Lower Extremity w/ + w/o Right,61673725,CDM,616,RC,73725,CPT,,,Inpatient,,,900,,,,80,,720,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,699.3,percent of total billed charges,,,95,,855,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,855,
RECOVERY ROOM 1ST 15 MINS,71000000,CDM,710,RC,,,,,Outpatient,,,93,,,,80,,74.4,percent of total billed charges,,,,85,79.05,percent of total billed charges,,,77.7,,72.26,percent of total billed charges,,,95,,88.35,percent of total billed charges,,,60,,55.8,percent of total billed charges,,55.8,88.35,
RECOVERY ROOM 1ST 15 MINS,71000000,CDM,710,RC,,,,,Inpatient,,,93,,,,80,,74.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,72.26,percent of total billed charges,,,95,,88.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,88.35,
RECOVERY ROOM EA ADDL 15 MINS,71000001,CDM,710,RC,,,,,Outpatient,,,66,,,,80,,52.8,percent of total billed charges,,,,85,56.1,percent of total billed charges,,,77.7,,51.28,percent of total billed charges,,,95,,62.7,percent of total billed charges,,,60,,39.6,percent of total billed charges,,39.6,62.7,
RECOVERY ROOM EA ADDL 15 MINS,71000001,CDM,710,RC,,,,,Inpatient,,,66,,,,80,,52.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,51.28,percent of total billed charges,,,95,,62.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,62.7,
RECOVERY ROOM PHASE II 1ST 15 MINS,71000002,CDM,710,RC,,,,,Outpatient,,,66,,,,80,,52.8,percent of total billed charges,,,,85,56.1,percent of total billed charges,,,77.7,,51.28,percent of total billed charges,,,95,,62.7,percent of total billed charges,,,60,,39.6,percent of total billed charges,,39.6,62.7,
RECOVERY ROOM PHASE II 1ST 15 MINS,71000002,CDM,710,RC,,,,,Inpatient,,,66,,,,80,,52.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,51.28,percent of total billed charges,,,95,,62.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,62.7,
RECOVERY ROOM PHASE II EA ADDL 15 MINS,71000003,CDM,710,RC,,,,,Outpatient,,,55,,,,80,,44,percent of total billed charges,,,,85,46.75,percent of total billed charges,,,77.7,,42.74,percent of total billed charges,,,95,,52.25,percent of total billed charges,,,60,,33,percent of total billed charges,,33,52.25,
RECOVERY ROOM PHASE II EA ADDL 15 MINS,71000003,CDM,710,RC,,,,,Inpatient,,,55,,,,80,,44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,42.74,percent of total billed charges,,,95,,52.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,52.25,
XR Sinuses Paranasal Complete,72070220,CDM,720,RC,70220,CPT,,,Outpatient,,,287,,,,80,,229.6,percent of total billed charges,,,,50,97.1,fee schedule,,,77.7,,223,percent of total billed charges,,,95,,272.65,percent of total billed charges,,,60,,172.2,percent of total billed charges,,172.2,272.65,
XR Sinuses Paranasal Complete,72070220,CDM,720,RC,70220,CPT,,,Inpatient,,,287,,,,80,,229.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,223,percent of total billed charges,,,95,,272.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,272.65,
CV ECG Acquisition,73093005,CDM,730,RC,93005,CPT,,,Outpatient,,,245,,,,80,,196,percent of total billed charges,,,,50,82.24,fee schedule,,,77.7,,190.37,percent of total billed charges,,,95,,232.75,percent of total billed charges,,,60,,147,percent of total billed charges,,147,232.75,
Electrocardiogram Tracing Only,73093005,CDM,730,RC,93005,CPT,,,Outpatient,,,245,,,,80,,196,percent of total billed charges,,,,50,82.24,fee schedule,,,77.7,,190.37,percent of total billed charges,,,95,,232.75,percent of total billed charges,,,60,,147,percent of total billed charges,,147,232.75,
CV ECG Acquisition,73093005,CDM,730,RC,93005,CPT,,,Inpatient,,,245,,,,80,,196,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,190.37,percent of total billed charges,,,95,,232.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,232.75,
Electrocardiogram Tracing Only,73093005,CDM,730,RC,93005,CPT,,,Inpatient,,,245,,,,80,,196,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,190.37,percent of total billed charges,,,95,,232.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,232.75,
Holter Monitoring > 48 HR < 7 Days,73093242,CDM,730,RC,93242,CPT,,,Outpatient,,,275,,,,80,,220,percent of total billed charges,,,,50,94.14,fee schedule,,,77.7,,213.68,percent of total billed charges,,,95,,261.25,percent of total billed charges,,,60,,165,percent of total billed charges,,165,261.25,
Holter Monitoring > 48 HR < 7 Days,73093242,CDM,730,RC,93242,CPT,,,Inpatient,,,275,,,,80,,220,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,213.68,percent of total billed charges,,,95,,261.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,261.25,
Holter Monitor >7 Days < 15 Days,73093246,CDM,730,RC,93246,CPT,,,Outpatient,,,275,,,,80,,220,percent of total billed charges,,,,50,94.14,fee schedule,,,77.7,,213.68,percent of total billed charges,,,95,,261.25,percent of total billed charges,,,60,,165,percent of total billed charges,,165,261.25,
Holter Monitor >7 Days < 15 Days,73093246,CDM,730,RC,93246,CPT,,,Inpatient,,,275,,,,80,,220,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,213.68,percent of total billed charges,,,95,,261.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,261.25,
OBSRV BLOOD ADMIN 0-8 HRS (PER DAY),76036430,CDM,762,RC,36430,CPT,,,Outpatient,,,668,,,,80,,534.4,percent of total billed charges,,,,50,257.85,fee schedule,,,77.7,,519.04,percent of total billed charges,,,95,,634.6,percent of total billed charges,,,60,,400.8,percent of total billed charges,,400.8,634.6,
OBSRV BLOOD ADMIN 0-8 HRS (PER DAY),76036430,CDM,762,RC,36430,CPT,,,Inpatient,,,668,,,,80,,534.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,519.04,percent of total billed charges,,,95,,634.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,634.6,
OBS STRAIGHT CATHETER INSERTION Charge,76051701,CDM,760,RC,51701,CPT,,,Outpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,50,72.45,fee schedule,,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,60,,157.06,percent of total billed charges,,157.06,248.68,
OBS STRAIGHT CATHETER INSERTION Charge,76051701,CDM,760,RC,51701,CPT,,,Inpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,248.68,
OBS FOLEY CATH INSERTION SIMPLE Charge,76051702,CDM,760,RC,51702,CPT,,,Outpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,50,72.45,fee schedule,,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,60,,157.06,percent of total billed charges,,157.06,248.68,
OBS FOLEY CATH INSERTION SIMPLE Charge,76051702,CDM,760,RC,51702,CPT,,,Inpatient,,,261.77,,,,80,,209.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,203.4,percent of total billed charges,,,95,,248.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,248.68,
OBS IV INFUS HYDRAT INIT 31 MIN-1HR Charge,76096360,CDM,760,RC,96360,CPT,,,Outpatient,,,339,,,,80,,271.2,percent of total billed charges,,,,50,114.91,fee schedule,,,77.7,,263.4,percent of total billed charges,,,95,,322.05,percent of total billed charges,,,60,,203.4,percent of total billed charges,,203.4,322.05,
OBS IV INFUS HYDRAT INIT 31 MIN-1HR Charge,76096360,CDM,760,RC,96360,CPT,,,Inpatient,,,339,,,,80,,271.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,263.4,percent of total billed charges,,,95,,322.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,322.05,
OBS 96361 IV HRDRA ADD'L > 90 MIN Charge,76096361,CDM,760,RC,96361,CPT,,,Outpatient,,,168,,,,80,,134.4,percent of total billed charges,,,,50,66.66,fee schedule,,,77.7,,130.54,percent of total billed charges,,,95,,159.6,percent of total billed charges,,,60,,100.8,percent of total billed charges,,100.8,159.6,
OBS IV INFU HYDRAT EA ADD'L HR 2ND,76096361,CDM,760,RC,96361,CPT,,,Outpatient,,,168,,,,80,,134.4,percent of total billed charges,,,,50,66.66,fee schedule,,,77.7,,130.54,percent of total billed charges,,,95,,159.6,percent of total billed charges,,,60,,100.8,percent of total billed charges,,100.8,159.6,
OBS 96361 IV HRDRA ADD'L > 90 MIN Charge,76096361,CDM,760,RC,96361,CPT,,,Inpatient,,,168,,,,80,,134.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,130.54,percent of total billed charges,,,95,,159.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,159.6,
OBS IV INFU HYDRAT EA ADD'L HR 2ND,76096361,CDM,760,RC,96361,CPT,,,Inpatient,,,168,,,,80,,134.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,130.54,percent of total billed charges,,,95,,159.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,159.6,
OBS IV INFU THER INITIAL 16-90 MIN  Charge,76096365,CDM,760,RC,96365,CPT,,,Outpatient,,,339,,,,80,,271.2,percent of total billed charges,,,,50,114.91,fee schedule,,,77.7,,263.4,percent of total billed charges,,,95,,322.05,percent of total billed charges,,,60,,203.4,percent of total billed charges,,203.4,322.05,
OBS IV INFU THER INITIAL 16-90 MIN  Charge,76096365,CDM,760,RC,96365,CPT,,,Inpatient,,,339,,,,80,,271.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,263.4,percent of total billed charges,,,95,,322.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,322.05,
OBS IV INFU THERAP EA ADD'L HR Charge >91 MINS,76096366,CDM,760,RC,96366,CPT,,,Outpatient,,,168,,,,80,,134.4,percent of total billed charges,,,,50,66.66,fee schedule,,,77.7,,130.54,percent of total billed charges,,,95,,159.6,percent of total billed charges,,,60,,100.8,percent of total billed charges,,100.8,159.6,
OBS IV INFU THERAP EA ADD'L HR Charge >91 MINS,76096366,CDM,760,RC,96366,CPT,,,Inpatient,,,168,,,,80,,134.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,130.54,percent of total billed charges,,,95,,159.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,159.6,
OBS IV INFU THERAP EA ADD'L SEQ NEW  Charge,76096367,CDM,760,RC,96367,CPT,,,Outpatient,,,198,,,,80,,158.4,percent of total billed charges,,,,50,66.66,fee schedule,,,77.7,,153.85,percent of total billed charges,,,95,,188.1,percent of total billed charges,,,60,,118.8,percent of total billed charges,,118.8,188.1,
OBS IV INFU THERAP EA ADD'L SEQ NEW  Charge,76096367,CDM,760,RC,96367,CPT,,,Inpatient,,,198,,,,80,,158.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,153.85,percent of total billed charges,,,95,,188.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,188.1,
OBS IV INFU THERAP CONCURRENT Charge,76096368,CDM,760,RC,96368,CPT,,,Outpatient,,,34,,,,80,,27.2,percent of total billed charges,,,,50,0.51,fee schedule,,,77.7,,26.42,percent of total billed charges,,,95,,32.3,percent of total billed charges,,,60,,20.4,percent of total billed charges,,20.4,32.3,
OBS IV INFU THERAP CONCURRENT Charge,76096368,CDM,760,RC,96368,CPT,,,Inpatient,,,34,,,,80,,27.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,26.42,percent of total billed charges,,,95,,32.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,32.3,
OBS IM OR SQ INJECTION PER STICK Charge,76096372,CDM,760,RC,96372,CPT,,,Outpatient,,,135,,,,80,,108,percent of total billed charges,,,,50,34.83,fee schedule,,,77.7,,104.9,percent of total billed charges,,,95,,128.25,percent of total billed charges,,,60,,81,percent of total billed charges,,81,128.25,
OBS IM OR SQ INJECTION PER STICK Charge,76096372,CDM,760,RC,96372,CPT,,,Inpatient,,,135,,,,80,,108,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,104.9,percent of total billed charges,,,95,,128.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,128.25,
OBS IV PUSH SINGLE OR INITIAL Charge,76096374,CDM,760,RC,96374,CPT,,,Outpatient,,,339,,,,80,,271.2,percent of total billed charges,,,,50,114.91,fee schedule,,,77.7,,263.4,percent of total billed charges,,,95,,322.05,percent of total billed charges,,,60,,203.4,percent of total billed charges,,203.4,322.05,
OBS IV PUSH SINGLE OR INITIAL Charge,76096374,CDM,760,RC,96374,CPT,,,Inpatient,,,339,,,,80,,271.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,263.4,percent of total billed charges,,,95,,322.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,322.05,
OBS IV PUSH EA ADD'L SEQ NEW DRUG Charge,76096375,CDM,760,RC,96375,CPT,,,Outpatient,,,86,,,,80,,68.8,percent of total billed charges,,,,50,21.72,fee schedule,,,77.7,,66.82,percent of total billed charges,,,95,,81.7,percent of total billed charges,,,60,,51.6,percent of total billed charges,,51.6,81.7,
OBS IV PUSH EA ADD'L SEQ NEW DRUG Charge,76096375,CDM,760,RC,96375,CPT,,,Inpatient,,,86,,,,80,,68.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,66.82,percent of total billed charges,,,95,,81.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,81.7,
OBS IV PUSH EA ADD'L SAME DRUG Charge,76096376,CDM,760,RC,96376,CPT,,,Outpatient,,,71,,,,80,,56.8,percent of total billed charges,,,,50,21.72,fee schedule,,,77.7,,55.17,percent of total billed charges,,,95,,67.45,percent of total billed charges,,,60,,42.6,percent of total billed charges,,42.6,67.45,
OBS IV PUSH EA ADD'L SAME DRUG Charge,76096376,CDM,760,RC,96376,CPT,,,Inpatient,,,71,,,,80,,56.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,55.17,percent of total billed charges,,,95,,67.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,67.45,
TR 10021 FNA W/O IMAGING,76110021,CDM,761,RC,10021,CPT,,,Outpatient,,,685,,,,80,,548,percent of total billed charges,,,,85,582.25,percent of total billed charges,,,77.7,,532.25,percent of total billed charges,,,95,,650.75,percent of total billed charges,,,60,,411,percent of total billed charges,,411,650.75,
TR 10021 FNA W/O IMAGING,76110021,CDM,761,RC,10021,CPT,,,Inpatient,,,685,,,,80,,548,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,532.25,percent of total billed charges,,,95,,650.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,650.75,
TR 10060 I&D ABSCESS SIMPLE SINGLE,76110060,CDM,761,RC,10060,CPT,,,Outpatient,,,1080,,,,80,,864,percent of total billed charges,,,,50,108.86,fee schedule,,,77.7,,839.16,percent of total billed charges,,,95,,1026,percent of total billed charges,,,60,,648,percent of total billed charges,,648,1026,
TR 10060 I&D ABSCESS SIMPLE SINGLE,76110060,CDM,761,RC,10060,CPT,,,Inpatient,,,1080,,,,80,,864,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,839.16,percent of total billed charges,,,95,,1026,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1026,
TR 11200 REMOVE SKIN TAGS UP TO 15 LES,76111200,CDM,761,RC,11200,CPT,,,Outpatient,,,2033,,,,80,,1626.4,percent of total billed charges,,,,50,108.86,fee schedule,,,77.7,,1579.64,percent of total billed charges,,,95,,1931.35,percent of total billed charges,,,60,,1219.8,percent of total billed charges,,1219.8,1931.35,
TR 11200 REMOVE SKIN TAGS UP TO 15 LES,76111200,CDM,761,RC,11200,CPT,,,Inpatient,,,2033,,,,80,,1626.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1579.64,percent of total billed charges,,,95,,1931.35,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1931.35,
TR 12002 REPAIR SIMP STHF 2.6 TO 7.5CM,76112002,CDM,761,RC,12002,CPT,,,Outpatient,,,574,,,,80,,459.2,percent of total billed charges,,,,50,228.77,fee schedule,,,77.7,,446,percent of total billed charges,,,95,,545.3,percent of total billed charges,,,60,,344.4,percent of total billed charges,,344.4,545.3,
TR 12002 REPAIR SIMP STHF 2.6 TO 7.5CM,76112002,CDM,761,RC,12002,CPT,,,Inpatient,,,574,,,,80,,459.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,446,percent of total billed charges,,,95,,545.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,545.3,
"TR 12011 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membra",76112011,CDM,761,RC,12011,CPT,,,Outpatient,,,597,,,,80,,477.6,percent of total billed charges,,,,50,237.86,fee schedule,,,77.7,,463.87,percent of total billed charges,,,95,,567.15,percent of total billed charges,,,60,,358.2,percent of total billed charges,,358.2,567.15,
"TR 12011 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membra",76112011,CDM,761,RC,12011,CPT,,,Inpatient,,,597,,,,80,,477.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,463.87,percent of total billed charges,,,95,,567.15,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,567.15,
20610 DRN/INJ MAJ JNT/BURSA BIL WO US Charge,76120610,CDM,761,RC,20610,CPT,,,Outpatient,,,450,,LT,,80,,360,percent of total billed charges,,,,50,165.27,fee schedule,,,77.7,,349.65,percent of total billed charges,,,95,,427.5,percent of total billed charges,,,60,,270,percent of total billed charges,,270,427.5,
TR 20610 BILAT DRN/INJ MAJ JNT/BURSA WO US,76120610,CDM,761,RC,20610,CPT,,,Outpatient,,,450,,RT,,80,,360,percent of total billed charges,,,,50,165.27,fee schedule,,,77.7,,349.65,percent of total billed charges,,,95,,427.5,percent of total billed charges,,,60,,270,percent of total billed charges,,270,427.5,
20610 DRN/INJ MAJ JNT/BURSA BIL WO US Charge,76120610,CDM,761,RC,20610,CPT,,,Inpatient,,,450,,LT,,80,,360,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,349.65,percent of total billed charges,,,95,,427.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,427.5,
TR 20610 BILAT DRN/INJ MAJ JNT/BURSA WO US,76120610,CDM,761,RC,20610,CPT,,,Inpatient,,,450,,RT,,80,,360,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,349.65,percent of total billed charges,,,95,,427.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,427.5,
TR 20611 DRAIN/INJ JNT/BURSA MAJ W/US Charge,76120611,CDM,761,RC,20611,CPT,,,Outpatient,,,525,,,,80,,420,percent of total billed charges,,,,50,165.27,fee schedule,,,77.7,,407.93,percent of total billed charges,,,95,,498.75,percent of total billed charges,,,60,,315,percent of total billed charges,,315,498.75,
TR 20611 DRAIN/INJ JNT/BURSA MAJ W/US Charge,76120611,CDM,761,RC,20611,CPT,,,Inpatient,,,525,,,,80,,420,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,407.93,percent of total billed charges,,,95,,498.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,498.75,
TR 30905 CTRL NSL HEMRRG PST NASAL PACKS&/CAUTERY 1ST,76130905,CDM,761,RC,30905,CPT,,,Outpatient,,,445,,,,80,,356,percent of total billed charges,,,,50,177.26,fee schedule,,,77.7,,345.77,percent of total billed charges,,,95,,422.75,percent of total billed charges,,,60,,267,percent of total billed charges,,267,422.75,
TR 30905 CTRL NSL HEMRRG PST NASAL PACKS&/CAUTERY 1ST,76130905,CDM,761,RC,30905,CPT,,,Inpatient,,,445,,,,80,,356,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,345.77,percent of total billed charges,,,95,,422.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,422.75,
TR 32555 ASPIRATE PLEURA W/ IMAGING,76132555,CDM,761,RC,32555,CPT,,,Outpatient,,,1256,,,,80,,1004.8,percent of total billed charges,,,,50,431.27,fee schedule,,,77.7,,975.91,percent of total billed charges,,,95,,1193.2,percent of total billed charges,,,60,,753.6,percent of total billed charges,,753.6,1193.2,
TR 32555 ASPIRATE PLEURA W/ IMAGING,76132555,CDM,761,RC,32555,CPT,,,Inpatient,,,1256,,,,80,,1004.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,975.91,percent of total billed charges,,,95,,1193.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1193.2,
TR 36000 INTRO NEEDLE OR INTRACATH VEIN,76136000,CDM,761,RC,36000,CPT,,,Outpatient,,,339,,,,80,,271.2,percent of total billed charges,,,,50,33.84,fee schedule,,,77.7,,263.4,percent of total billed charges,,,95,,322.05,percent of total billed charges,,,60,,203.4,percent of total billed charges,,203.4,322.05,
TR 36000 INTRO NEEDLE OR INTRACATH VEIN,76136000,CDM,761,RC,36000,CPT,,,Inpatient,,,339,,,,80,,271.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,263.4,percent of total billed charges,,,95,,322.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,322.05,
TR 36430 BLOOD ADMIN 0-8HRS (PER DAY),76136430,CDM,761,RC,36430,CPT,,,Outpatient,,,668,,,,80,,534.4,percent of total billed charges,,,,50,257.85,fee schedule,,,77.7,,519.04,percent of total billed charges,,,95,,634.6,percent of total billed charges,,,60,,400.8,percent of total billed charges,,400.8,634.6,
TR 36430 BLOOD ADMIN 0-8HRS (PER DAY),76136430,CDM,761,RC,36430,CPT,,,Inpatient,,,668,,,,80,,534.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,519.04,percent of total billed charges,,,95,,634.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,634.6,
TR 36589 REMOVE CENTRAL VENOUS CATHETER Charge,76136589,CDM,761,RC,36589,CPT,,,Outpatient,,,1576,,,,80,,1260.8,percent of total billed charges,,,,50,479.25,fee schedule,,,77.7,,1224.55,percent of total billed charges,,,95,,1497.2,percent of total billed charges,,,60,,945.6,percent of total billed charges,,945.6,1497.2,
TR 36589 REMOVE CENTRAL VENOUS CATHETER Charge,76136589,CDM,761,RC,36589,CPT,,,Inpatient,,,1576,,,,80,,1260.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1224.55,percent of total billed charges,,,95,,1497.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1497.2,
TR 43762 REPLACE GTUBE W/O REVISION GASTRO TRACT,76143762,CDM,761,RC,43762,CPT,,,Outpatient,,,632,,,,80,,505.6,percent of total billed charges,,,,50,231.29,fee schedule,,,77.7,,491.06,percent of total billed charges,,,95,,600.4,percent of total billed charges,,,60,,379.2,percent of total billed charges,,379.2,600.4,
TR 43762 REPLACE GTUBE W/O REVISION GASTRO TRACT,76143762,CDM,761,RC,43762,CPT,,,Inpatient,,,632,,,,80,,505.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,491.06,percent of total billed charges,,,95,,600.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,600.4,
TR 59412 EXTERNAL CEPHALIC VERSION W/WO TOCOLYSIS,76159412,CDM,761,RC,59412,CPT,,,Outpatient,,,2680,,,,80,,2144,percent of total billed charges,,,,85,2278,percent of total billed charges,,,77.7,,2082.36,percent of total billed charges,,,95,,2546,percent of total billed charges,,,60,,1608,percent of total billed charges,,1608,2546,
TR 59412 EXTERNAL CEPHALIC VERSION W/WO TOCOLYSIS,76159412,CDM,761,RC,59412,CPT,,,Inpatient,,,2680,,,,80,,2144,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2082.36,percent of total billed charges,,,95,,2546,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2546,
TR 96361 IV HRDRA ADD'L > 90 MIN Charge,76196361,CDM,761,RC,96361,CPT,,,Outpatient,,,168,,,,80,,134.4,percent of total billed charges,,,,50,66.66,fee schedule,,,77.7,,130.54,percent of total billed charges,,,95,,159.6,percent of total billed charges,,,60,,100.8,percent of total billed charges,,100.8,159.6,
TR 96361 IV HRDRA ADD'L > 90 MIN Charge,76196361,CDM,761,RC,96361,CPT,,,Inpatient,,,168,,,,80,,134.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,130.54,percent of total billed charges,,,95,,159.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,159.6,
TR 96365 IV THER. INITIAL 16-90 MIN Charge,76196365,CDM,761,RC,96365,CPT,,,Outpatient,,,339,,,,80,,271.2,percent of total billed charges,,,,50,114.91,fee schedule,,,77.7,,263.4,percent of total billed charges,,,95,,322.05,percent of total billed charges,,,60,,203.4,percent of total billed charges,,203.4,322.05,
TR 96365 IV THER. INITIAL 16-90 MIN Charge,76196365,CDM,761,RC,96365,CPT,,,Inpatient,,,339,,,,80,,271.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,263.4,percent of total billed charges,,,95,,322.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,322.05,
TR 96366 IV THER. ADD'L HRS > 91 MINS Charge,76196366,CDM,761,RC,96366,CPT,,,Outpatient,,,168,,,,80,,134.4,percent of total billed charges,,,,50,66.66,fee schedule,,,77.7,,130.54,percent of total billed charges,,,95,,159.6,percent of total billed charges,,,60,,100.8,percent of total billed charges,,100.8,159.6,
TR 96366 IV THER. ADD'L HRS > 91 MINS Charge,76196366,CDM,761,RC,96366,CPT,,,Inpatient,,,168,,,,80,,134.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,130.54,percent of total billed charges,,,95,,159.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,159.6,
TR 96372 IM OR SQ INJECTION PER STICK,76196372,CDM,761,RC,96372,CPT,,,Outpatient,,,135,,,,80,,108,percent of total billed charges,,,,50,34.83,fee schedule,,,77.7,,104.9,percent of total billed charges,,,95,,128.25,percent of total billed charges,,,60,,81,percent of total billed charges,,81,128.25,
TR 96372 IM OR SQ INJECTION PER STICK,76196372,CDM,761,RC,96372,CPT,,,Inpatient,,,135,,,,80,,108,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,104.9,percent of total billed charges,,,95,,128.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,128.25,
TR 96374 IV PUSH SINGLE OR INITIAL,76196374,CDM,761,RC,96374,CPT,,,Outpatient,,,339,,,,80,,271.2,percent of total billed charges,,,,50,114.91,fee schedule,,,77.7,,263.4,percent of total billed charges,,,95,,322.05,percent of total billed charges,,,60,,203.4,percent of total billed charges,,203.4,322.05,
TR 96374 IV PUSH SINGLE OR INITIAL,76196374,CDM,761,RC,96374,CPT,,,Inpatient,,,339,,,,80,,271.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,263.4,percent of total billed charges,,,95,,322.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,322.05,
TR 96415 CHEMO THERAPEUTIC EA ADD'L Charge,76196415,CDM,761,RC,96415,CPT,,,Outpatient,,,280,,,,80,,224,percent of total billed charges,,,,50,97.97,fee schedule,,,77.7,,217.56,percent of total billed charges,,,95,,266,percent of total billed charges,,,60,,168,percent of total billed charges,,168,266,
TR 96415 CHEMO THERAPEUTIC EA ADD'L Charge,76196415,CDM,761,RC,96415,CPT,,,Inpatient,,,280,,,,80,,224,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,217.56,percent of total billed charges,,,95,,266,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,266,
TR 96522 REFILL/MAINT PUMP/RESVR SYST,76196522,CDM,761,RC,96522,CPT,,,Outpatient,,,414,,,,80,,331.2,percent of total billed charges,,,,85,351.9,percent of total billed charges,,,77.7,,321.68,percent of total billed charges,,,95,,393.3,percent of total billed charges,,,60,,248.4,percent of total billed charges,,248.4,393.3,
TR 96522 REFILL/MAINT PUMP/RESVR SYST,76196522,CDM,761,RC,96522,CPT,,,Inpatient,,,414,,,,80,,331.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,321.68,percent of total billed charges,,,95,,393.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,393.3,
TR 96523 IRRIGATE IMPLANT VEN ACC DEVICE,76196523,CDM,761,RC,96523,CPT,,,Outpatient,,,69,,,,80,,55.2,percent of total billed charges,,,,50,27.27,fee schedule,,,77.7,,53.61,percent of total billed charges,,,95,,65.55,percent of total billed charges,,,60,,41.4,percent of total billed charges,,41.4,65.55,
TR 96523 IRRIGATE IMPLANT VEN ACC DEVICE,76196523,CDM,761,RC,96523,CPT,,,Inpatient,,,69,,,,80,,55.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,53.61,percent of total billed charges,,,95,,65.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,65.55,
US Carotid Doppler Bilateral,92193880,CDM,921,RC,93880,CPT,,,Outpatient,,,683,,,,80,,546.4,percent of total billed charges,,,,50,240.38,fee schedule,,,77.7,,530.69,percent of total billed charges,,,95,,648.85,percent of total billed charges,,,60,,409.8,percent of total billed charges,,409.8,648.85,
US Carotid Doppler Bilateral,92193880,CDM,921,RC,93880,CPT,,,Inpatient,,,683,,,,80,,546.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,530.69,percent of total billed charges,,,95,,648.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,648.85,
US UE Venous Duplex Left,92193971,CDM,921,RC,93971,CPT,,,Outpatient,,,824,,,,80,,659.2,percent of total billed charges,,,,50,240.38,fee schedule,,,77.7,,640.25,percent of total billed charges,,,95,,782.8,percent of total billed charges,,,60,,494.4,percent of total billed charges,,494.4,782.8,
US UE Venous Duplex Right,92193971,CDM,921,RC,93971,CPT,,,Outpatient,,,824,,,,80,,659.2,percent of total billed charges,,,,50,240.38,fee schedule,,,77.7,,640.25,percent of total billed charges,,,95,,782.8,percent of total billed charges,,,60,,494.4,percent of total billed charges,,494.4,782.8,
US UE Venous Duplex Left,92193971,CDM,921,RC,93971,CPT,,,Inpatient,,,824,,,,80,,659.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,640.25,percent of total billed charges,,,95,,782.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,782.8,
US UE Venous Duplex Right,92193971,CDM,921,RC,93971,CPT,,,Inpatient,,,824,,,,80,,659.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,640.25,percent of total billed charges,,,95,,782.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,782.8,
Pulm Rehab w/Continuous Oximetry,94894626,CDM,460,RC,94626,CPT,,,Outpatient,,,565,,,,80,,452,percent of total billed charges,,,,50,266.99,fee schedule,,,77.7,,439.01,percent of total billed charges,,,95,,536.75,percent of total billed charges,,,60,,339,percent of total billed charges,,339,536.75,
Pulm Rehab w/Continuous Oximetry,94894626,CDM,948,RC,94626,CPT,,,Outpatient,,,565,,,,80,,452,percent of total billed charges,,,,50,266.99,fee schedule,,,77.7,,439.01,percent of total billed charges,,,95,,536.75,percent of total billed charges,,,60,,339,percent of total billed charges,,339,536.75,
Pulm Rehab w/Continuous Oximetry,94894626,CDM,460,RC,94626,CPT,,,Inpatient,,,565,,,,80,,452,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,439.01,percent of total billed charges,,,95,,536.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,536.75,
Pulm Rehab w/Continuous Oximetry,94894626,CDM,948,RC,94626,CPT,,,Inpatient,,,565,,,,80,,452,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,439.01,percent of total billed charges,,,95,,536.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,536.75,
ER 92977 THROMBOLYSIS CORONARY BY IV,317092977,CDM,450,RC,92977,CPT,,,Outpatient,,,945,,,,80,,756,percent of total billed charges,,,,50,371.18,fee schedule,,,77.7,,734.27,percent of total billed charges,,,95,,897.75,percent of total billed charges,,,60,,567,percent of total billed charges,,567,897.75,
ER 92977 THROMBOLYSIS CORONARY BY IV,317092977,CDM,450,RC,92977,CPT,,,Inpatient,,,945,,,,80,,756,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,734.27,percent of total billed charges,,,95,,897.75,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,897.75,
"Paliperidone, Serum - LC",341980342,CDM,309,RC,80342,CPT,,,Outpatient,,,239,,,,80,,191.2,percent of total billed charges,,,,50,31.33,fee schedule,,,77.7,,185.7,percent of total billed charges,,,95,,227.05,percent of total billed charges,,,60,,143.4,percent of total billed charges,,143.4,227.05,
"Paliperidone, Serum - LC",341980342,CDM,309,RC,80342,CPT,,,Inpatient,,,239,,,,80,,191.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,185.7,percent of total billed charges,,,95,,227.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,227.05,
"Fecal Fat, Qualitative LC",341982705,CDM,309,RC,82705,CPT,,,Outpatient,,,63,,,,80,,50.4,percent of total billed charges,,,,50,8.86,fee schedule,,,77.7,,48.95,percent of total billed charges,,,95,,59.85,percent of total billed charges,,,60,,37.8,percent of total billed charges,,37.8,59.85,
"Fecal Fat, Qualitative LC",341982705,CDM,309,RC,82705,CPT,,,Inpatient,,,63,,,,80,,50.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,48.95,percent of total billed charges,,,95,,59.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,59.85,
Osmolality - LC,341983930,CDM,309,RC,83930,CPT,,,Outpatient,,,83,,,,80,,66.4,percent of total billed charges,,,,50,14.35,fee schedule,,,77.7,,64.49,percent of total billed charges,,,95,,78.85,percent of total billed charges,,,60,,49.8,percent of total billed charges,,49.8,78.85,
Osmolality - LC,341983930,CDM,309,RC,83930,CPT,,,Inpatient,,,83,,,,80,,66.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,64.49,percent of total billed charges,,,95,,78.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,78.85,
SARS-CoV-2 Antibody IgG - LC,341986769,CDM,309,RC,86769,CPT,,,Outpatient,,,75,,,,80,,60,percent of total billed charges,,,,50,11.35,fee schedule,,,77.7,,58.28,percent of total billed charges,,,95,,71.25,percent of total billed charges,,,60,,45,percent of total billed charges,,45,71.25,
SARS-CoV-2 Antibody IgG - LC,341986769,CDM,309,RC,86769,CPT,,,Inpatient,,,75,,,,80,,60,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,58.28,percent of total billed charges,,,95,,71.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,71.25,
"White Blood Cells (WBC), Stool - LC",341989055,CDM,309,RC,89055,CPT,,,Outpatient,,,44,,,,80,,35.2,percent of total billed charges,,,,50,7.53,fee schedule,,,77.7,,34.19,percent of total billed charges,,,95,,41.8,percent of total billed charges,,,60,,26.4,percent of total billed charges,,26.4,41.8,
"White Blood Cells (WBC), Stool - LC",341989055,CDM,309,RC,89055,CPT,,,Inpatient,,,44,,,,80,,35.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,34.19,percent of total billed charges,,,95,,41.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,41.8,
XR Abdomen AP,344074018,CDM,320,RC,74018,CPT,,,Outpatient,,,204,,,,80,,163.2,percent of total billed charges,,,,50,67.37,fee schedule,,,77.7,,158.51,percent of total billed charges,,,95,,193.8,percent of total billed charges,,,60,,122.4,percent of total billed charges,,122.4,193.8,
XR Abdomen AP,344074018,CDM,320,RC,74018,CPT,,,Inpatient,,,204,,,,80,,163.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,158.51,percent of total billed charges,,,95,,193.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,193.8,
Arm Sling,270A4565,CDM,270,RC,A4565,HCPCS,,,Outpatient,,,6.66,,,,80,,5.33,percent of total billed charges,,,,85,5.66,percent of total billed charges,,,77.7,,5.17,percent of total billed charges,,,95,,6.33,percent of total billed charges,,,60,,4,percent of total billed charges,,4,6.33,
Arm Sling,270A4565,CDM,270,RC,A4565,HCPCS,,,Inpatient,,,6.66,,,,80,,5.33,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.17,percent of total billed charges,,,95,,6.33,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.33,
PO SPLINT CERVICAL COLLAR,274L0120,CDM,274,RC,L0120,HCPCS,,,Outpatient,,,9.81,,,,80,,7.85,percent of total billed charges,,,,85,8.34,percent of total billed charges,,,77.7,,7.62,percent of total billed charges,,,95,,9.32,percent of total billed charges,,,60,,5.89,percent of total billed charges,,5.89,9.32,
PO SPLINT COLLAR UNIVERSAL,274L0120,CDM,274,RC,L0120,HCPCS,,,Outpatient,,,9.81,,,,80,,7.85,percent of total billed charges,,,,85,8.34,percent of total billed charges,,,77.7,,7.62,percent of total billed charges,,,95,,9.32,percent of total billed charges,,,60,,5.89,percent of total billed charges,,5.89,9.32,
PO SPLINT CERVICAL COLLAR,274L0120,CDM,274,RC,L0120,HCPCS,,,Inpatient,,,9.81,,,,80,,7.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.62,percent of total billed charges,,,95,,9.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.32,
PO SPLINT COLLAR UNIVERSAL,274L0120,CDM,274,RC,L0120,HCPCS,,,Inpatient,,,9.81,,,,80,,7.85,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.62,percent of total billed charges,,,95,,9.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.32,
PO SPLINT LUMBOSACRAL,274L0628,CDM,274,RC,L0628,HCPCS,,,Outpatient,,,42.84,,,,80,,34.27,percent of total billed charges,,,,50,38.57,fee schedule,,,77.7,,33.29,percent of total billed charges,,,95,,40.7,percent of total billed charges,,,60,,25.7,percent of total billed charges,,25.7,40.7,
PO SPLINT LUMBOSACRAL,274L0628,CDM,274,RC,L0628,HCPCS,,,Inpatient,,,42.84,,,,80,,34.27,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,33.29,percent of total billed charges,,,95,,40.7,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,40.7,
PO SPLINT KNEE LOCKING JOINT,274L1831,CDM,274,RC,L1831,HCPCS,,,Outpatient,,,139.13,,,,80,,111.3,percent of total billed charges,,,,50,139.85,fee schedule,,,77.7,,108.1,percent of total billed charges,,,95,,132.17,percent of total billed charges,,,60,,83.48,percent of total billed charges,,83.48,139.85,
PO SPLINT KNEE LOCKING JOINT,274L1831,CDM,274,RC,L1831,HCPCS,,,Inpatient,,,139.13,,,,80,,111.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,108.1,percent of total billed charges,,,95,,132.17,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,132.17,
PO SPLINT KNEE IMMOBILIZER,274L1836,CDM,274,RC,L1836,HCPCS,,,Outpatient,,,182.74,,,,80,,146.19,percent of total billed charges,,,,85,155.33,percent of total billed charges,,,77.7,,141.99,percent of total billed charges,,,95,,173.6,percent of total billed charges,,,60,,109.64,percent of total billed charges,,109.64,173.6,
PO SPLINT KNEE IMMOBILIZER,274L1836,CDM,274,RC,L1836,HCPCS,,,Inpatient,,,182.74,,,,80,,146.19,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,141.99,percent of total billed charges,,,95,,173.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,173.6,
Ankle Lace-up W/Velcro,274L1902,CDM,274,RC,L1902,HCPCS,,,Outpatient,,,31.73,,,,80,,25.38,percent of total billed charges,,,,85,26.97,percent of total billed charges,,,77.7,,24.65,percent of total billed charges,,,95,,30.14,percent of total billed charges,,,60,,19.04,percent of total billed charges,,19.04,30.14,
PO SPLINT ORTHOSIS ANKLE,274L1902,CDM,274,RC,L1902,HCPCS,,,Outpatient,,,28.8,,,,80,,23.04,percent of total billed charges,,,,85,24.48,percent of total billed charges,,,77.7,,22.38,percent of total billed charges,,,95,,27.36,percent of total billed charges,,,60,,17.28,percent of total billed charges,,17.28,27.36,
Ankle Lace-up W/Velcro,274L1902,CDM,274,RC,L1902,HCPCS,,,Inpatient,,,31.73,,,,80,,25.38,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,24.65,percent of total billed charges,,,95,,30.14,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,30.14,
PO SPLINT ORTHOSIS ANKLE,274L1902,CDM,274,RC,L1902,HCPCS,,,Inpatient,,,28.8,,,,80,,23.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,22.38,percent of total billed charges,,,95,,27.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,27.36,
AFO Off-Shelf Rigid Plas,274L1930,CDM,274,RC,L1930,HCPCS,,,Outpatient,,,6.07,,,,80,,4.86,percent of total billed charges,,,,50,158.94,fee schedule,,,77.7,,4.72,percent of total billed charges,,,95,,5.77,percent of total billed charges,,,60,,3.64,percent of total billed charges,,3.64,158.94,
AFO Off-Shelf Rigid Plas,274L1930,CDM,274,RC,L1930,HCPCS,,,Inpatient,,,6.07,,,,80,,4.86,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.72,percent of total billed charges,,,95,,5.77,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.77,
PO SPLINT CLAVICLE,274L3650,CDM,274,RC,L3650,HCPCS,,,Outpatient,,,11.85,,,,80,,9.48,percent of total billed charges,,,,85,10.07,percent of total billed charges,,,77.7,,9.21,percent of total billed charges,,,95,,11.26,percent of total billed charges,,,60,,7.11,percent of total billed charges,,7.11,11.26,
PO SPLINT CLAVICLE,274L3650,CDM,274,RC,L3650,HCPCS,,,Inpatient,,,11.85,,,,80,,9.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,9.21,percent of total billed charges,,,95,,11.26,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,11.26,
PO SHOULDER ORTH/8 ABDUCTION PREFAB,274L3660,CDM,274,RC,L3660,HCPCS,,,Outpatient,,,17.67,,,,80,,14.14,percent of total billed charges,,,,50,50.63,fee schedule,,,77.7,,13.73,percent of total billed charges,,,95,,16.79,percent of total billed charges,,,60,,10.6,percent of total billed charges,,10.6,50.63,
PO SHOULDER ORTH/8 ABDUCTION PREFAB,274L3660,CDM,274,RC,L3660,HCPCS,,,Inpatient,,,17.67,,,,80,,14.14,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,13.73,percent of total billed charges,,,95,,16.79,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,16.79,
C WHFO STATIC,274L3807,CDM,274,RC,L3807,HCPCS,,,Outpatient,,,114.66,,,,80,,91.73,percent of total billed charges,,,,85,97.46,percent of total billed charges,,,77.7,,89.09,percent of total billed charges,,,95,,108.93,percent of total billed charges,,,60,,68.8,percent of total billed charges,,68.8,108.93,
C WHFO STATIC,274L3807,CDM,274,RC,L3807,HCPCS,,,Inpatient,,,114.66,,,,80,,91.73,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,89.09,percent of total billed charges,,,95,,108.93,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,108.93,
P WHO STATIC,274L3908,CDM,274,RC,L3908,HCPCS,,,Outpatient,,,15.99,,,,80,,12.79,percent of total billed charges,,,,85,13.59,percent of total billed charges,,,77.7,,12.42,percent of total billed charges,,,95,,15.19,percent of total billed charges,,,60,,9.59,percent of total billed charges,,9.59,15.19,
Wrist Hand Orthosis,274L3908,CDM,274,RC,L3908,HCPCS,,,Outpatient,,,15.99,,,,80,,12.79,percent of total billed charges,,,,85,13.59,percent of total billed charges,,,77.7,,12.42,percent of total billed charges,,,95,,15.19,percent of total billed charges,,,60,,9.59,percent of total billed charges,,9.59,15.19,
P WHO STATIC,274L3908,CDM,274,RC,L3908,HCPCS,,,Inpatient,,,15.99,,,,80,,12.79,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.42,percent of total billed charges,,,95,,15.19,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.19,
Wrist Hand Orthosis,274L3908,CDM,274,RC,L3908,HCPCS,,,Inpatient,,,15.99,,,,80,,12.79,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.42,percent of total billed charges,,,95,,15.19,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.19,
P WHFO DYNAMIC,274L3931,CDM,274,RC,L3931,HCPCS,,,Outpatient,,,229.53,,,,80,,183.62,percent of total billed charges,,,,50,97.88,fee schedule,,,77.7,,178.34,percent of total billed charges,,,95,,218.05,percent of total billed charges,,,60,,137.72,percent of total billed charges,,97.88,218.05,
P WHFO DYNAMIC,274L3931,CDM,274,RC,L3931,HCPCS,,,Inpatient,,,229.53,,,,80,,183.62,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,178.34,percent of total billed charges,,,95,,218.05,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,218.05,
PO ANKLE BRACE PREFAB W FA,274L4350,CDM,274,RC,L4350,HCPCS,,,Outpatient,,,41.13,,,,80,,32.9,percent of total billed charges,,,,85,34.96,percent of total billed charges,,,77.7,,31.96,percent of total billed charges,,,95,,39.07,percent of total billed charges,,,60,,24.68,percent of total billed charges,,24.68,39.07,
PO SPLINT AIRCAST ANKLE,274L4350,CDM,274,RC,L4350,HCPCS,,,Outpatient,,,41.13,,,,80,,32.9,percent of total billed charges,,,,85,34.96,percent of total billed charges,,,77.7,,31.96,percent of total billed charges,,,95,,39.07,percent of total billed charges,,,60,,24.68,percent of total billed charges,,24.68,39.07,
PO ANKLE BRACE PREFAB W FA,274L4350,CDM,274,RC,L4350,HCPCS,,,Inpatient,,,41.13,,,,80,,32.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,31.96,percent of total billed charges,,,95,,39.07,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,39.07,
PO SPLINT AIRCAST ANKLE,274L4350,CDM,274,RC,L4350,HCPCS,,,Inpatient,,,41.13,,,,80,,32.9,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,31.96,percent of total billed charges,,,95,,39.07,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,39.07,
PO NON-PNEUM WALK BOOT PRE CST,274L4386,CDM,274,RC,L4386,HCPCS,,,Outpatient,,,101.57,,,,80,,81.26,percent of total billed charges,,,,85,86.33,percent of total billed charges,,,77.7,,78.92,percent of total billed charges,,,95,,96.49,percent of total billed charges,,,60,,60.94,percent of total billed charges,,60.94,96.49,
PO NON-PNEUM WALK BOOT PRE CST,274L4386,CDM,274,RC,L4386,HCPCS,,,Inpatient,,,101.57,,,,80,,81.26,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,78.92,percent of total billed charges,,,95,,96.49,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,96.49,
STATIC AFO,274L4396,CDM,274,RC,L4396,HCPCS,,,Outpatient,,,73.82,,,,80,,59.06,percent of total billed charges,,,,50,91.95,fee schedule,,,77.7,,57.36,percent of total billed charges,,,95,,70.13,percent of total billed charges,,,60,,44.29,percent of total billed charges,,44.29,91.95,
STATIC AFO,274L4396,CDM,274,RC,L4396,HCPCS,,,Inpatient,,,73.82,,,,80,,59.06,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,57.36,percent of total billed charges,,,95,,70.13,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,70.13,
"SARS Cov-2, Influenza A/B, RSV Panel",3000241U,CDM,300,RC,0241U,HCPCS,,,Outpatient,,,278,,,,80,,222.4,percent of total billed charges,,,,50,699.43,fee schedule,,,77.7,,216.01,percent of total billed charges,,,95,,264.1,percent of total billed charges,,,60,,166.8,percent of total billed charges,,166.8,699.43,
"SARS Cov-2, Influenza A/B, RSV Panel",3000241U,CDM,300,RC,0241U,HCPCS,,,Inpatient,,,278,,,,80,,222.4,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,216.01,percent of total billed charges,,,95,,264.1,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,264.1,
Fecal Occult Blood Screen - IA,300G0328,CDM,300,RC,G0328,HCPCS,,,Outpatient,,,50,,,,80,,40,percent of total billed charges,,,,50,17.07,fee schedule,,,77.7,,38.85,percent of total billed charges,,,95,,47.5,percent of total billed charges,,,60,,30,percent of total billed charges,,17.07,47.5,
Fecal Occult Blood Screen - IA,300G0328,CDM,300,RC,G0328,HCPCS,,,Inpatient,,,50,,,,80,,40,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,38.85,percent of total billed charges,,,95,,47.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,47.5,
Catheterization for Urine Collection P9612,300P9612,CDM,300,RC,P9612,HCPCS,,,Outpatient,,,76.25,,,,80,,61,percent of total billed charges,,,,85,64.81,percent of total billed charges,,,77.7,,59.25,percent of total billed charges,,,95,,72.44,percent of total billed charges,,,60,,45.75,percent of total billed charges,,45.75,72.44,
Catheterization for Urine Collection P9612,300P9612,CDM,300,RC,P9612,HCPCS,,,Inpatient,,,76.25,,,,80,,61,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,59.25,percent of total billed charges,,,95,,72.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,72.44,
P9016 PACKED RBC LEUKOCYTE REDUCED,390P9016,CDM,390,RC,P9016,HCPCS,,,Outpatient,,,741,,,,80,,592.8,percent of total billed charges,,,,50,267.17,fee schedule,,,77.7,,575.76,percent of total billed charges,,,95,,703.95,percent of total billed charges,,,60,,444.6,percent of total billed charges,,267.17,703.95,
P9016 PACKED RBC LEUKOCYTE REDUCED,390P9016,CDM,390,RC,P9016,HCPCS,,,Inpatient,,,741,,,,80,,592.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,575.76,percent of total billed charges,,,95,,703.95,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,703.95,
P9017 FRESH FROZEN PLASMA,390P9017,CDM,390,RC,P9017,HCPCS,,,Outpatient,,,230,,,,80,,184,percent of total billed charges,,,,85,195.5,percent of total billed charges,,,77.7,,178.71,percent of total billed charges,,,95,,218.5,percent of total billed charges,,,60,,138,percent of total billed charges,,138,218.5,
P9017 FRESH FROZEN PLASMA,390P9017,CDM,390,RC,P9017,HCPCS,,,Inpatient,,,230,,,,80,,184,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,178.71,percent of total billed charges,,,95,,218.5,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,218.5,
P9021 Packed Red Blood Cells,390P9021,CDM,390,RC,P9021,HCPCS,,,Outpatient,,,175,,,,80,,140,percent of total billed charges,,,,85,148.75,percent of total billed charges,,,77.7,,135.98,percent of total billed charges,,,95,,166.25,percent of total billed charges,,,60,,105,percent of total billed charges,,105,166.25,
P9021 Packed Red Blood Cells,390P9021,CDM,390,RC,P9021,HCPCS,,,Inpatient,,,175,,,,80,,140,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,135.98,percent of total billed charges,,,95,,166.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,166.25,
P9035 PLATELET PHERESIS LEUKOREDUCED,390P9035,CDM,390,RC,P9035,HCPCS,,,Outpatient,,,1104,,,,80,,883.2,percent of total billed charges,,,,85,938.4,percent of total billed charges,,,77.7,,857.81,percent of total billed charges,,,95,,1048.8,percent of total billed charges,,,60,,662.4,percent of total billed charges,,662.4,1048.8,
P9035 PLATELET PHERESIS LEUKOREDUCED,390P9035,CDM,390,RC,P9035,HCPCS,,,Inpatient,,,1104,,,,80,,883.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,857.81,percent of total billed charges,,,95,,1048.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1048.8,
G0239 Other Resp Proc Group Per 15 Min,460G0239,CDM,460,RC,G0239,HCPCS,,,Outpatient,,,60,,,,80,,48,percent of total billed charges,,,,50,23.74,fee schedule,,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,60,,36,percent of total billed charges,,23.74,57,
G0239 Other Resp Proc Group Per 15 Min,460G0239,CDM,460,RC,G0239,HCPCS,,,Inpatient,,,60,,,,80,,48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,46.62,percent of total billed charges,,,95,,57,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,57,
CONSTANT ICE PACKS,CDM,CDM,270,RC,,,,,Outpatient,,,2.3,,,,80,,1.84,percent of total billed charges,,,,85,1.96,percent of total billed charges,,,77.7,,1.79,percent of total billed charges,,,95,,2.19,percent of total billed charges,,,60,,1.38,percent of total billed charges,,1.38,2.19,
IV STARTER KIT,CDM,CDM,270,RC,,,,,Outpatient,,,2.9,,,,80,,2.32,percent of total billed charges,,,,85,2.47,percent of total billed charges,,,77.7,,2.25,percent of total billed charges,,,95,,2.76,percent of total billed charges,,,60,,1.74,percent of total billed charges,,1.74,2.76,
CONSTANT ICE PACKS,CDM,CDM,270,RC,,,,,Inpatient,,,2.3,,,,80,,1.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.79,percent of total billed charges,,,95,,2.19,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.19,
IV STARTER KIT,CDM,CDM,270,RC,,,,,Inpatient,,,2.9,,,,80,,2.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.25,percent of total billed charges,,,95,,2.76,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,2.76,
Admin Charge (Influenza Intranasal Vaccine) -> G0008 Admin Influenza Intranasal,G0008,CDM,521,RC,G0008,HCPCS,,,Outpatient,,,24,,,,80,,19.2,percent of total billed charges,,,,50,4.04,fee schedule,,,77.7,,18.65,percent of total billed charges,,,95,,22.8,percent of total billed charges,,,60,,14.4,percent of total billed charges,,4.04,22.8,
Admin Charge (Influenza Vaccine) -> G0008 Admin Influenza,G0008,CDM,771,RC,G0008,HCPCS,,,Outpatient,,,24,,,,80,,19.2,percent of total billed charges,,,,50,4.04,fee schedule,,,77.7,,18.65,percent of total billed charges,,,95,,22.8,percent of total billed charges,,,60,,14.4,percent of total billed charges,,4.04,22.8,
Admin Charge (Influenza Intranasal Vaccine) -> G0008 Admin Influenza Intranasal,G0008,CDM,521,RC,G0008,HCPCS,,,Inpatient,,,24,,,,80,,19.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,18.65,percent of total billed charges,,,95,,22.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,22.8,
Admin Charge (Influenza Vaccine) -> G0008 Admin Influenza,G0008,CDM,771,RC,G0008,HCPCS,,,Inpatient,,,24,,,,80,,19.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,18.65,percent of total billed charges,,,95,,22.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,22.8,
Admin Charge (Pneumococcal Vaccine) -> G0009 Admin Pneumococcal,G0009,CDM,521,RC,G0009,HCPCS,,,Outpatient,,,24,,,,80,,19.2,percent of total billed charges,,,,50,4.04,fee schedule,,,77.7,,18.65,percent of total billed charges,,,95,,22.8,percent of total billed charges,,,60,,14.4,percent of total billed charges,,4.04,22.8,
Admin Charge (Pneumococcal Vaccine) -> G0009 Admin Pneumococcal,G0009,CDM,521,RC,G0009,HCPCS,,,Inpatient,,,24,,,,80,,19.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,18.65,percent of total billed charges,,,95,,22.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,22.8,
Admin Charge (Hepatitis B Vaccine) -> G0010 Admin Hepatitis B,G0010,CDM,521,RC,G0010,HCPCS,,,Outpatient,,,20,,,,80,,16,percent of total billed charges,,,,85,17,percent of total billed charges,,,77.7,,15.54,percent of total billed charges,,,95,,19,percent of total billed charges,,,60,,12,percent of total billed charges,,12,19,
Admin Charge (Hepatitis B Vaccine) -> G0010 Admin Hepatitis B,G0010,CDM,521,RC,G0010,HCPCS,,,Inpatient,,,20,,,,80,,16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,15.54,percent of total billed charges,,,95,,19,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,19,
PEROXIDE 16 OZ,KHKS- 102453,CDM,270,RC,,,,,Outpatient,,,54.2,,,,80,,43.36,percent of total billed charges,,,,85,46.07,percent of total billed charges,,,77.7,,42.11,percent of total billed charges,,,95,,51.49,percent of total billed charges,,,60,,32.52,percent of total billed charges,,32.52,51.49,
PEROXIDE 16 OZ,KHKS- 102453,CDM,270,RC,,,,,Inpatient,,,54.2,,,,80,,43.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,42.11,percent of total billed charges,,,95,,51.49,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,51.49,
FILTER EXTEN. SET 1.2 FILTER,KHKS-100713,CDM,270,RC,,,,,Outpatient,,,13.3,,,,80,,10.64,percent of total billed charges,,,,85,11.31,percent of total billed charges,,,77.7,,10.33,percent of total billed charges,,,95,,12.64,percent of total billed charges,,,60,,7.98,percent of total billed charges,,7.98,12.64,
FILTER EXTEN. SET 1.2 FILTER,KHKS-100713,CDM,270,RC,,,,,Inpatient,,,13.3,,,,80,,10.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,10.33,percent of total billed charges,,,95,,12.64,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,12.64,
"SURE PRESS COMPRESSION BANDAGE 4""",KHKS-100782,CDM,270,RC,,,,,Outpatient,,,28.9,,,,80,,23.12,percent of total billed charges,,,,85,24.57,percent of total billed charges,,,77.7,,22.46,percent of total billed charges,,,95,,27.46,percent of total billed charges,,,60,,17.34,percent of total billed charges,,17.34,27.46,
"SURE PRESS COMPRESSION BANDAGE 4""",KHKS-100782,CDM,270,RC,,,,,Inpatient,,,28.9,,,,80,,23.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,22.46,percent of total billed charges,,,95,,27.46,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,27.46,
CENTRAL LINE DRESSING KIT,KHKS-100862,CDM,270,RC,,,,,Outpatient,,,9.6,,,,80,,7.68,percent of total billed charges,,,,85,8.16,percent of total billed charges,,,77.7,,7.46,percent of total billed charges,,,95,,9.12,percent of total billed charges,,,60,,5.76,percent of total billed charges,,5.76,9.12,
CENTRAL LINE DRESSING KIT,KHKS-100862,CDM,270,RC,,,,,Inpatient,,,9.6,,,,80,,7.68,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.46,percent of total billed charges,,,95,,9.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.12,
CANNULA HI FLOW NASAL,KHKS-100912,CDM,270,RC,,,,,Outpatient,,,9.9,,,,80,,7.92,percent of total billed charges,,,,85,8.42,percent of total billed charges,,,77.7,,7.69,percent of total billed charges,,,95,,9.41,percent of total billed charges,,,60,,5.94,percent of total billed charges,,5.94,9.41,
CANNULA HI FLOW NASAL,KHKS-100912,CDM,270,RC,,,,,Inpatient,,,9.9,,,,80,,7.92,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,7.69,percent of total billed charges,,,95,,9.41,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,9.41,
PERFORMA TRAK MEDIUM,KHKS-101066,CDM,270,RC,,,,,Outpatient,,,88.4,,,,80,,70.72,percent of total billed charges,,,,85,75.14,percent of total billed charges,,,77.7,,68.69,percent of total billed charges,,,95,,83.98,percent of total billed charges,,,60,,53.04,percent of total billed charges,,53.04,83.98,
PERFORMA TRAK MEDIUM,KHKS-101066,CDM,270,RC,,,,,Inpatient,,,88.4,,,,80,,70.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,68.69,percent of total billed charges,,,95,,83.98,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,83.98,
L3809 WRIST THUMB MED LT SPLINT,KHKS-101450,CDM,274,RC,L3809,HCPCS,,,Outpatient,,,43.6,,,,80,,34.88,percent of total billed charges,,,,85,37.06,percent of total billed charges,,,77.7,,33.88,percent of total billed charges,,,95,,41.42,percent of total billed charges,,,60,,26.16,percent of total billed charges,,26.16,41.42,
L3809 WRIST THUMB MED LT SPLINT,KHKS-101450,CDM,274,RC,L3809,HCPCS,,,Inpatient,,,43.6,,,,80,,34.88,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,33.88,percent of total billed charges,,,95,,41.42,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,41.42,
MICROBORE EXT W/SPIN COLLAR,KHKS-101569,CDM,270,RC,,,,,Outpatient,,,5.6,,,,80,,4.48,percent of total billed charges,,,,85,4.76,percent of total billed charges,,,77.7,,4.35,percent of total billed charges,,,95,,5.32,percent of total billed charges,,,60,,3.36,percent of total billed charges,,3.36,5.32,
MICROBORE EXT W/SPIN COLLAR,KHKS-101569,CDM,270,RC,,,,,Inpatient,,,5.6,,,,80,,4.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.35,percent of total billed charges,,,95,,5.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.32,
STRYKER XPRESS ULTRA ENT DILATION SYSYTEM,KHKS-101584,CDM,278,RC,C1726,HCPCS,,,Outpatient,,,5695.9,,,,80,,4556.72,percent of total billed charges,,,,85,4841.52,percent of total billed charges,,,77.7,,4425.71,percent of total billed charges,,,95,,5411.11,percent of total billed charges,,,60,,3417.54,percent of total billed charges,,3417.54,5411.11,
STRYKER XPRESS ULTRA ENT DILATION SYSYTEM,KHKS-101584,CDM,278,RC,C1726,HCPCS,,,Inpatient,,,5695.9,,,,80,,4556.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4425.71,percent of total billed charges,,,95,,5411.11,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5411.11,
CIRCUIT VAPOTHERM HIGH FLOW,KHKS-101804,CDM,270,RC,,,,,Outpatient,,,445.2,,,,80,,356.16,percent of total billed charges,,,,85,378.42,percent of total billed charges,,,77.7,,345.92,percent of total billed charges,,,95,,422.94,percent of total billed charges,,,60,,267.12,percent of total billed charges,,267.12,422.94,
CIRCUIT VAPOTHERM HIGH FLOW,KHKS-101804,CDM,270,RC,,,,,Inpatient,,,445.2,,,,80,,356.16,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,345.92,percent of total billed charges,,,95,,422.94,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,422.94,
BACKCHECK VALVE,KHKS-102196,CDM,270,RC,,,,,Outpatient,,,31.5,,,,80,,25.2,percent of total billed charges,,,,85,26.78,percent of total billed charges,,,77.7,,24.48,percent of total billed charges,,,95,,29.93,percent of total billed charges,,,60,,18.9,percent of total billed charges,,18.9,29.93,
BACKCHECK VALVE,KHKS-102196,CDM,270,RC,,,,,Inpatient,,,31.5,,,,80,,25.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,24.48,percent of total billed charges,,,95,,29.93,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,29.93,
CERVICAL RIPENING BALLOON W/STYLET,KHKS-102224,CDM,270,RC,,,,,Outpatient,,,204.3,,,,80,,163.44,percent of total billed charges,,,,85,173.66,percent of total billed charges,,,77.7,,158.74,percent of total billed charges,,,95,,194.09,percent of total billed charges,,,60,,122.58,percent of total billed charges,,122.58,194.09,
CERVICAL RIPENING BALLOON W/STYLET,KHKS-102224,CDM,270,RC,,,,,Inpatient,,,204.3,,,,80,,163.44,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,158.74,percent of total billed charges,,,95,,194.09,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,194.09,
YANKAUER SUCTION,KHKS-102389,CDM,270,RC,,,,,Outpatient,,,1.2,,,,80,,0.96,percent of total billed charges,,,,85,1.02,percent of total billed charges,,,77.7,,0.93,percent of total billed charges,,,95,,1.14,percent of total billed charges,,,60,,0.72,percent of total billed charges,,0.72,1.14,
YANKAUER SUCTION,KHKS-102389,CDM,270,RC,,,,,Inpatient,,,1.2,,,,80,,0.96,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,0.93,percent of total billed charges,,,95,,1.14,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.14,
VENOSET,KHKS-102447,CDM,270,RC,,,,,Outpatient,,,14.8,,,,80,,11.84,percent of total billed charges,,,,85,12.58,percent of total billed charges,,,77.7,,11.5,percent of total billed charges,,,95,,14.06,percent of total billed charges,,,60,,8.88,percent of total billed charges,,8.88,14.06,
VENOSET,KHKS-102447,CDM,270,RC,,,,,Inpatient,,,14.8,,,,80,,11.84,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.5,percent of total billed charges,,,95,,14.06,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,14.06,
IV EXTENDER,KHKS-102510,CDM,270,RC,,,,,Outpatient,,,17.9,,,,80,,14.32,percent of total billed charges,,,,85,15.22,percent of total billed charges,,,77.7,,13.91,percent of total billed charges,,,95,,17.01,percent of total billed charges,,,60,,10.74,percent of total billed charges,,10.74,17.01,
IV EXTENDER,KHKS-102510,CDM,270,RC,,,,,Inpatient,,,17.9,,,,80,,14.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,13.91,percent of total billed charges,,,95,,17.01,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,17.01,
LUKI-TUBE,KHKS-102541,CDM,270,RC,,,,,Outpatient,,,4.5,,,,80,,3.6,percent of total billed charges,,,,85,3.83,percent of total billed charges,,,77.7,,3.5,percent of total billed charges,,,95,,4.28,percent of total billed charges,,,60,,2.7,percent of total billed charges,,2.7,4.28,
LUKI-TUBE,KHKS-102541,CDM,270,RC,,,,,Inpatient,,,4.5,,,,80,,3.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.5,percent of total billed charges,,,95,,4.28,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,4.28,
"L3908 WRIST SPLINT UNIV LT 7""",KHKS-102567,CDM,274,RC,L3908,HCPCS,,,Outpatient,,,16,,,,80,,12.8,percent of total billed charges,,,,85,13.6,percent of total billed charges,,,77.7,,12.43,percent of total billed charges,,,95,,15.2,percent of total billed charges,,,60,,9.6,percent of total billed charges,,9.6,15.2,
"L3908 WRIST SPLINT UNIV LT 7""",KHKS-102567,CDM,274,RC,L3908,HCPCS,,,Inpatient,,,16,,,,80,,12.8,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,12.43,percent of total billed charges,,,95,,15.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,15.2,
ANESTHESIA MASK TODDLER,KHKS-102678,CDM,270,RC,,,,,Outpatient,,,5.6,,,,80,,4.48,percent of total billed charges,,,,85,4.76,percent of total billed charges,,,77.7,,4.35,percent of total billed charges,,,95,,5.32,percent of total billed charges,,,60,,3.36,percent of total billed charges,,3.36,5.32,
ANESTHESIA MASK TODDLER,KHKS-102678,CDM,270,RC,,,,,Inpatient,,,5.6,,,,80,,4.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,4.35,percent of total billed charges,,,95,,5.32,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,5.32,
CLAVE CONNECTOR,KHKS-102693,CDM,270,RC,,,,,Outpatient,,,3.8,,,,80,,3.04,percent of total billed charges,,,,85,3.23,percent of total billed charges,,,77.7,,2.95,percent of total billed charges,,,95,,3.61,percent of total billed charges,,,60,,2.28,percent of total billed charges,,2.28,3.61,
CLAVE CONNECTOR,KHKS-102693,CDM,270,RC,,,,,Inpatient,,,3.8,,,,80,,3.04,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,2.95,percent of total billed charges,,,95,,3.61,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.61,
COMBO DEFIB PATCHES - ADULT,KHKS-102751,CDM,270,RC,,,,,Outpatient,,,75.9,,,,80,,60.72,percent of total billed charges,,,,85,64.52,percent of total billed charges,,,77.7,,58.97,percent of total billed charges,,,95,,72.11,percent of total billed charges,,,60,,45.54,percent of total billed charges,,45.54,72.11,
COMBO DEFIB PATCHES - ADULT,KHKS-102751,CDM,270,RC,,,,,Inpatient,,,75.9,,,,80,,60.72,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,58.97,percent of total billed charges,,,95,,72.11,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,72.11,
CANNULA INFANT,KHKS-102760,CDM,270,RC,,,,,Outpatient,,,3.9,,,,80,,3.12,percent of total billed charges,,,,85,3.32,percent of total billed charges,,,77.7,,3.03,percent of total billed charges,,,95,,3.71,percent of total billed charges,,,60,,2.34,percent of total billed charges,,2.34,3.71,
CANNULA INFANT,KHKS-102760,CDM,270,RC,,,,,Inpatient,,,3.9,,,,80,,3.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,3.03,percent of total billed charges,,,95,,3.71,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,3.71,
UTERINE ASPIRATING TUBING,KHKS-102876,CDM,270,RC,,,,,Outpatient,,,19.2,,,,80,,15.36,percent of total billed charges,,,,85,16.32,percent of total billed charges,,,77.7,,14.92,percent of total billed charges,,,95,,18.24,percent of total billed charges,,,60,,11.52,percent of total billed charges,,11.52,18.24,
UTERINE ASPIRATING TUBING,KHKS-102876,CDM,270,RC,,,,,Inpatient,,,19.2,,,,80,,15.36,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,14.92,percent of total billed charges,,,95,,18.24,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,18.24,
IRRIGATION SOLUTION SC 500ML USP Plastic Pour Bottle,KHKS-102982,CDM,250,RC,,,,,Outpatient,,,11.5,,,,80,,9.2,percent of total billed charges,,,,85,9.78,percent of total billed charges,,,77.7,,8.94,percent of total billed charges,,,95,,10.93,percent of total billed charges,,,60,,6.9,percent of total billed charges,,6.9,10.93,
IRRIGATION SOLUTION SC 500ML USP Plastic Pour Bottle,KHKS-102982,CDM,250,RC,,,,,Inpatient,,,11.5,,,,80,,9.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,8.94,percent of total billed charges,,,95,,10.93,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,10.93,
NOVII PATCH,KHKS-103042,CDM,270,RC,,,,,Outpatient,,,153.1,,,,80,,122.48,percent of total billed charges,,,,85,130.14,percent of total billed charges,,,77.7,,118.96,percent of total billed charges,,,95,,145.45,percent of total billed charges,,,60,,91.86,percent of total billed charges,,91.86,145.45,
NOVII PATCH,KHKS-103042,CDM,270,RC,,,,,Inpatient,,,153.1,,,,80,,122.48,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,118.96,percent of total billed charges,,,95,,145.45,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,145.45,
"DISPOSABLE SINUS DEBRIDER 4MM MALLEABLE, CELERIS",KHKS-103043,CDM,270,RC,,,,,Outpatient,,,1134,,,,80,,907.2,percent of total billed charges,,,,85,963.9,percent of total billed charges,,,77.7,,881.12,percent of total billed charges,,,95,,1077.3,percent of total billed charges,,,60,,680.4,percent of total billed charges,,680.4,1077.3,
"DISPOSABLE SINUS DEBRIDER 4MM MALLEABLE, CELERIS",KHKS-103043,CDM,270,RC,,,,,Inpatient,,,1134,,,,80,,907.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,881.12,percent of total billed charges,,,95,,1077.3,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1077.3,
"ORAL RAE TRACH TUBE,CUFFED,7.0MM",KHKS-103072,CDM,270,RC,,,,,Outpatient,,,14.5,,,,80,,11.6,percent of total billed charges,,,,85,12.33,percent of total billed charges,,,77.7,,11.27,percent of total billed charges,,,95,,13.78,percent of total billed charges,,,60,,8.7,percent of total billed charges,,8.7,13.78,
"ORAL RAE TRACH TUBE,CUFFED,7.0MM",KHKS-103072,CDM,270,RC,,,,,Inpatient,,,14.5,,,,80,,11.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,11.27,percent of total billed charges,,,95,,13.78,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,13.78,
NONBREATHER OXYGEN MASK ADULT,KHKS103073,CDM,270,RC,,,,,Outpatient,,,7,,,,80,,5.6,percent of total billed charges,,,,85,5.95,percent of total billed charges,,,77.7,,5.44,percent of total billed charges,,,95,,6.65,percent of total billed charges,,,60,,4.2,percent of total billed charges,,4.2,6.65,
NONBREATHER OXYGEN MASK ADULT,KHKS103073,CDM,270,RC,,,,,Inpatient,,,7,,,,80,,5.6,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,5.44,percent of total billed charges,,,95,,6.65,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,6.65,
SUCTION CATHETER W/ 10FR,KHKS-103076,CDM,270,RC,,,,,Outpatient,,,1.4,,,,80,,1.12,percent of total billed charges,,,,85,1.19,percent of total billed charges,,,77.7,,1.09,percent of total billed charges,,,95,,1.33,percent of total billed charges,,,60,,0.84,percent of total billed charges,,0.84,1.33,
SUCTION CATHETER W/ 10FR,KHKS-103076,CDM,270,RC,,,,,Inpatient,,,1.4,,,,80,,1.12,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,1.09,percent of total billed charges,,,95,,1.33,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,1.33,
"SUTURE,PDS,II, O-CTX,VIOLET",KHKS-103107,CDM,270,RC,,,,,Outpatient,,,9,,,,80,,7.2,percent of total billed charges,,,,85,7.65,percent of total billed charges,,,77.7,,6.99,percent of total billed charges,,,95,,8.55,percent of total billed charges,,,60,,5.4,percent of total billed charges,,5.4,8.55,
"SUTURE,PDS,II, O-CTX,VIOLET",KHKS-103107,CDM,270,RC,,,,,Inpatient,,,9,,,,80,,7.2,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,6.99,percent of total billed charges,,,95,,8.55,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,8.55,
20FR REPLACEMENT G-TUBE STRAIGHT,KHKS-103130,CDM,270,RC,,,,,Outpatient,,,96.9,,,,80,,77.52,percent of total billed charges,,,,85,82.37,percent of total billed charges,,,77.7,,75.29,percent of total billed charges,,,95,,92.06,percent of total billed charges,,,60,,58.14,percent of total billed charges,,58.14,92.06,
20FR REPLACEMENT G-TUBE STRAIGHT,KHKS-103130,CDM,270,RC,,,,,Inpatient,,,96.9,,,,80,,77.52,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,75.29,percent of total billed charges,,,95,,92.06,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,92.06,
EPIPATCH,KHKS-103135,CDM,270,RC,,,,,Outpatient,,,875,,,,80,,700,percent of total billed charges,,,,85,743.75,percent of total billed charges,,,77.7,,679.88,percent of total billed charges,,,95,,831.25,percent of total billed charges,,,60,,525,percent of total billed charges,,525,831.25,
EPIPATCH,KHKS-103135,CDM,270,RC,,,,,Inpatient,,,875,,,,80,,700,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,77.7,,679.88,percent of total billed charges,,,95,,831.25,percent of total billed charges,,,,,,other,drg based reimbursement/drg is configured based on documentation and additional factors/drg is not a chargemaster value,,831.25,